CC# 24-17 EMS 3rd party Biller and Collection Agency.pdf

PROJECT MANUAL

for

CC# 24-17

COMPETITIVE CONTRACT

THIRD PARTY BILLER EMS/EMS COLLECTION SERVICES

City of Cape May, Cape May County, N.J.

July 16, 2024 at 11:00AM

MAYOR & COUNCIL

Mayor Zachary Mullock

Councilmember Lorraine Baldwin

Councilmember Shaine P. Meier

Councilmember Michael Yeager

Councilmember Maureen K. McDade

Erin C. Burke, RMC, City Clerk

Paul Dietrich, City Manager

Competitive Contract Request for Proposals

Notice is hereby given by the City of Cape May that a Competitive Contract in accord with N.J.S.A. 40A:11-4.1 will be received by the City on July 16, 2024 at 11:00AM prevailing time conducted on electronic platform, in accord with N.J.A.C. 5:34-1 et. Seq., on BIDNET at www.bidnetdirect.com//capemaycity

CC #24-17 COMPETITIVE CONTRACT

THIRD PARTY BILLER EMS/EMS COLLECTION SERVICES

NOTE:

It is the bidder’s responsibility to ensure that the bid package is uploaded onto the e-procurement site by the bid opening date and time. Any bid document received after the deadline established by the Department of Purchasing will not be accepted, regardless of the method of delivery.

Bidders must comply with the requirements of N.J.S.A. 10:5-31 et seq., and

N.J.A.C. 17:27 et. Seq., For zoom opening information, contact the Qualified Purchasing Agent at scanning@TheCanningGroup.org

The City of Cape May will award this Competitive Contract in accord with Price and

Other Factors as outlined within N.J.S.A 40A:11-4.1 et. Seq., and N.J.A.C. 5:34-4.1 et. Seq., Report of Competitive Contract:

In accord with N.J.S.A. 40A:11-4.4(d) the summary report will be posted on the City procurement website at www.bidnetdirect.com//capemaycity at least 48 hours prior to the governing body taking action on award.

This procurement has been advertised in accordance with the “Fair and Open Basis”

(N.J.S.A. 19:44A-20.5).

Ordered By: Erin C. Burke

City Clerk http://www.bidnetdirect.com/capemaycity mailto:scanning@TheCanningGroup.org

Applicable to Bid if marked “X”

DOCUMENTATION REQUIRED OR REVIEWED

Initials When Due

Bid Guarantee (Bid Bond or Certified/Cashier’s Check) (with

POA for full amount of Bid Bond)

With Bid

Submission

Consent of Surety (Certificate from Surety company)

Performance Bond and Labor and Material Payment Bond

(Required from the Awarded Contractor)

At signing of contract

Maintenance Bond in the Amount of 100 % for a period indicated in “General Conditions” Required from the Awarded

Contractor Upon Acceptance of Project

Upon

Acceptance of

Project

Acknowledgement of Receipt of Addenda (To be Completed if Addenda are Issued)

X Ownership Disclosure Form With Bid

Submission

Named Subcontractors in Bid for Listed Specialty Trades

Public Works Contractor Registration Certificate(s) for the

Bidder and all Sub Contractors

Prior to Award, but effective at time of bid

X Business Registration Certificate – Bidder and all Sub

Contractors

Prior to

Contract

Award

X Non-Collusion Affidavit With Bid

Submission

X Experience and Qualifications With Bid

Submission

X Insurance and Indemnification Certificate

Prior to

Contract

Award

X Disclosure of Investment Activities in Russa Form

Prior to

Contract

Award

X Disclosure of Investment Activities in Iran Form

Prior to

Contract

Award

Federal debarment Form

Prior to

Contract

Award

Prevailing Wage Certification (PL 2021, C301)

Prior to

Contract

Award

Equipment Certification

EEO/AA Form AA-201

After Notice of

Award, Prior to

Signing

Contract

X EEO/AA Form AA-302 or Letter of Federal Approval or

Certificate of Employee Information Report

After Notice of

Award, Prior to

Signing

Contract

X Bidder’s Checklist

This checklist is provided for bidder’s use in assuring compliance with required documentation; however, it does not include all specifications requirements and does not relieve the bidder of the need to read and comply with the specifications.

Bidder

Name:

Date:

Authorized

Representative:

Signature:

Print Name &

Title:

COMPETITIVE CONTRACT

CITYOF CAPE MAY

1.0 OVERVIEW & GENERAL INFORMATION

1.1 The City of Cape May (the "City ") is seeking proposals to obtain services of an independent contractor to provide certain patient accounting, third-party billing services as well as collections services for the The City of Cape May Ambulance

Services for an initial five (5) year in accord with N.J.S.A. 40A:11-4.1 et. Seq.,

1.2 This is a new procurement for the City and the services are based upon the anticipated workload.

1.3 Vendors can respond to:

• 3rd Party Billing Services

• Collection Services

• #3rd Party and Collection Services combined.

1.4 The City is anticipating service to commence on or about September 1, 2024.

Vendors responding to this procurement should be capable of providing service in a rapid fast paced environment, adapting to the needs of the City.

2.0 SCOPE OF WORK

2.1 The City of Cape May currently has a total of four (4) ambulances. The EMS standard on each response vehicle is Basic Life Support level. The City of Cape

May Council establishes user fees for persons using the department’s ambulances for transportation.

The fee schedule is listed herein:

CITY OF CAPE MAY FEE RESOLUTION:

Emergency medical services transport fee.

The fee schedule for emergency medical services transport by the City of Cape May is as follows:

2.2 Base rate: The base rate is $850 per transport. This rate includes the dispatch of two EMTs; services of basic life support; and emergency ambulance transportation.

2.3 Mileage charge: A mileage charge of $14.00 per mile shall be added to the base rate.

2.4 Other fees (See updated resolution attached):

2.4.1 Oxygen administration: $95.00

2.4.2 Disposable cervical collar: $35.00

2.4.3 AED administration: $95.00

2.4.4 EpiPen: $175.00

2.4.5 Extra Attendant/Bariatric $125.00

2.4.6 Narcan administration: $150.00

2.5 Third-party plan for emergency medical services:

2.5.1 The vendor will provide for switchover of any current vendor in the instance of a vendor change.

2.5.2 Most residents have a health insurance plan or Medicare/Medicaid which provides payments to relieve their payment obligations; and

2.5.3 It is in the best interest of the taxpayers of the City to fully utilize the payment plan in accordance with Health Care Finance

Administration guidelines (HCFA) so that taxpayers will not be responsible for any out-of-pocket expenses.

2.5.4 Billing responsibility: The City Manager and the City Chief Financial

Officer, in consultation with the municipality's Tax Collector, will be responsible for the plans billing.

3.0 MANDATORY MINIMUM REQUIREMENTS

3.1 The contractor must meet the following mandatory minimum requirements to be considered responsive to this Request for Proposals. The City shall not consider any proposals that do not meet these minimum requirements and no further evaluation shall be necessary.

3.2 Third Party Billers must adhere and comply with the State of New Jersey regulations and statutes at:

3.2.1 N.J.S.A. 17B:27B-1 et. Seq.,

3.2.2 Be approved and listed by the New Jersey Division of Banking and Insurance as an approved third-party biller.

3.3 The contractor must provide assurance with a certification statement that the contractor is committed to complying with the Standards for Privacy of

Individually Identifiable Health Information (the "Privacy Rule") under the Health

Insurance Portability and Accountability Act of 1996 ("HIPAA"), and has developed and implemented internal practices, books, and records relating to the use and disclosure of Protected Health

3.4 The contractor must demonstrate a record of successful performance providing billing services to private and/or public run heath care facilities; The contractor must possess extensive background, knowledge and experience in the operation of a comprehensive patient accounting and billing system compliant with HIPAA.

3.5 The contractor must possess extensive background, knowledge and experience relating to Medicare and Medicaid billing.

The contractor must be licensed by the Commissioner of the New Jersey Department of

Banking and Insurance to provide third party billing services pursuant to N.J.A.C. 11:23-5.1 et seq. The contractor shall provide a copy of its license with their proposal. If the contractor is not licensed, a license must be obtained and furnished to the City prior to contract award. Loss of appropriate licensure by the contractor may result in the suspension and/or termination of the contract.

4.0 PROCESS AND RESPONSIBILITY OF VENDOR

4.1 The successful Offeror shall promptly undertake through ethical and lawful means, the billing and collection of the City of Cape May’s Emergency Medical Service

(EMS) fees imposed on the users of this service, with particular attention to the

Consumer Credit Protection Act, Fair Debt Collection Act overseen by the New

Jersey Department of Consumer Affairs, and all other laws applicable to this type of activity.

4.2 Indicate, in detail, the Offeror’s approach in providing services in the following three areas:

4.2.1 Current Billing & Collections – The Offeror shall outline the current billing and collection process and itemize all costs associated with the process.

4.2.2 Delinquent Billing & Collections – The Offeror shall outline the delinquent billing and collection process and itemize all costs associated with the process.

4.2.3 Electronic Patient Reporting – The Offeror shall provide electronic patient reporting software. The offer shall completely specify the capabilities of the software proposed, to include billing software.

4.2.4 Training - Provide detailed information for training of City staff if necessary, to include annual HIPPA training for all City employees.

4.2.5 Project Management - Indicate Offeror’s approach to

managing the project.

4.2.6 Include a timeline showing the necessary activities and schedule for implementation of the project. Describe the various responsibilities and coordination of your team members for effective project management.

4.2.7 The Offeror will provide the following minimum services.

4.2.8 City of Cape May for preparation of monthly statements and/or third-party filings to an electronic format of reporting. Any software training for the City of Cape May’s Emergency Medical Service staff will be done in the City and at the Offeror’s expense.

4.2.9 Calculate mileage for billing from point of pickup to destination.

4.2.10 Obtain any missing data necessary for billing from either the receiving hospital or from the patient by telephone or in person.

(Using the U.S. Postal Service for such inquiries are discouraged and only viable if telephone contact numbers are unavailable.)

4.2.11 File claims, electronically or by using appropriate forms, on behalf of patients with Medicare, Medicaid, Worker’s Compensation, Personal Injury Protection, and third- party insurance companies.

4.2.12 Gather, extract and transmit data collected from patient run information.

4.2.13 Adhere to and implement current privacy standards of Health Insurance Portability and

Accountability Act (HIPAA) requirements. Follow national electronic data interchange

(EDI) standards and use national standard codes such as HCPCS, CPT, and CDT.

4.2.14 Adhere to and be aware of the current billing requirements and contractual restrictions dictated by the Centers of Medicare and Medicaid Services, New Jersey law and regulations, the Health Insurance Portability and Accountability Act, and the New Jersey

Worker’s Compensation Commission and shall hold the City harmless for any billing errors due to the Contractor’s activity.

Send the patient or the patient’s responsible party a statement advising the status of the claim every thirty days.

4.2.15 Collect all EMS account fees and establish monthly payment plans, when necessary, for patients financially unable to make one full payment.

4.2.16 The City of Cape May will notify the Contractor of any direct payments and will credit the Contractor with the contractual rate for all such direct payments collected after the

Contractor begins active collection efforts.

4.2.17 The Contractor shall suspend the billing and collecting efforts on any EMS account upon written notice to do so by a representative of the City, The City may recall any EMS account, all at no cost to the City, except for fees earned prior thereto.

4.2.18 The Contractor shall not have the right to refuse to bill and collect any EMS fee.

4.2.19 The Contractor shall maintain adequate records of the services performed such as invoicing, statement and dunning letter processing for audit by the City. All such records shall be available for inspection and audit, without prior notice, by the City of Cape

May.

4.2.20 All standard billing, collecting, and account status reporting formats will be in a format acceptable to the City. The Offeror’s proposal shall include proposed sample reports and the desired schedule for furnishing each. Minimum report requirements on access to online portal.

4.2.21 Report of accounts receivable; including the beginning balance, all EMS charges billed, payments received, any adjustments, and the ending accounts receivable balance.

4.2.22 An aged trial balance of outstanding EMS accounts.

4.2.23 Summary historical report of Offeror performance; including the number of runs billed, EMS fees billed, collected and the patient category, i.e. self-pay, private insurance, Medicare, Medicaid, and the collection rate.

4.2.24 A summary of refunds for overpayment.

4.2.25 Detail report of all charge adjustments.

4.2.26 A summary of bad debt and non-allowable write-offs.

4.2.27 Will provide all patients with a follow up survey.

5.0 OFFEROR QUESTIONNAIRE

5.1 The following questions must be answered and returned as part of your RFP. Failure to do so will result in disqualification. Evaluation of this questionnaire will be a major factor in the award of this contract.

5.2 What type of technical resources does your firm have?

5.3 What type of financial resources does your firm have?

5.4 How long has your firm been in business? (years)

5.5 List any past or present lawsuits filed against your firm.

5.6 How many employees will be assigned to this project?

5.7 Provide a resume for each member of your work force who will be working with fee billing and collecting of the City of Cape May’s EMS accounts.

5.8 Who will be supervising the work to be performed under this contract and what is the person's experience (years of experience, certification, qualifications, etc.)?

5.9 Provide an overall work plan for achieving the RFP (i.e. analytical steps involved).

5.10 Explain the role of the contractor as related to City staff, including the division of work between the contractor and City staff.

5.11 How many and what type of local branches and agencies throughout the continental United States does your firm have?

5.12 Provide the street address and contact person's name for your firm and identify the location where the actual collection efforts will take place.

5.13 Provide disclosure and supporting documentation, such as a "collection policy", that will be used by the agency when directing collection service personnel on dealing with accounts by the telephone or in writing. Provide sample letters and telephone scripts.

5.14 Provide disclosure and supporting copies of any and all standard invoices, release and assignment of benefits forms, statements and dunning notices presently being utilized.

5.15 List contracts you presently have with other municipalities, local government agencies or other ambulance transport service providers and other contact information as provider.

6 ACTIVITY

6.1 Call Volume

6.2 2020-1271

6.3 2021- 1408

6.4 2022- 1473

6.5 2023- 1346

8 EMS COLLECTION SERVICES FOR THE CITY

8.1 SCOPE OF WORK

8.1.1 The purpose of the competitive contract is to obtain a qualified provider to provide

EMS Collection Services for the City of Cape May.

9 GENERAL GUIDELINES AND REQUIREMENTS

9.1 Accounts to be turned over for collections will on average be 180 days past due. The number of accounts turned over to collections during the last 3 calendar years with the corresponding dollar amounts are as follows:

9.1.1 2022 $41,740.95 – 85 accounts

9.1.2 2023 $46,313.88 - 80 accounts

9.2 The provider shall have sufficient staff and facilities to provide a full scope of collection services, including, but not limited to, mail tracings.

9.3 In the Collection of debt, the provider must adhere to public law.

9.4 When and if litigation becomes necessary, no action may take place until a thorough credit study is completed at no charge to City of Cape May EMS and the provider must obtain prior written permission from the City of Cape May attorney.

9.5 In the event a debtor contacts City of Cape May EMS after an account is transferred to the provider, they will be referred to the provider for further handling.

9.6 The provider attests that it shall obey all laws, standards, prudent business practices, and ethics in collecting accounts. Debtors shall not be subjected to undue intimidation or threats to secure collection.

9.7 The provider shall provide and pay for all materials, labor, attorney and or legal fees, incidentals, and all other services and or facilities of any nature whatsoever that may become necessary to execute, complete and deliver quality service.

9.8 The provider will be required to provide proof of registration as a commercial collection agency in good standing with the State of Florida and appropriate local licensure.

9.9 Provider must permit audits, as requested by City of Cape May internal and/or external auditors.

City of Cape May EMS will not be responsible for the costs of any audits.

9.10 Providers must agree not to add, delete, or change in any way, an account without prior authorization from City of Cape May EMS.

9.11 Provider must submit a yearly report of all accounts received, collected and outstanding, including an explanation of all accounts which have not had any payment activity. The provider shall also be required to submit no less than monthly a list of all accounts it deems uncollectible with a detailed description of all collection efforts undertaken and rationale for conclusion to the

City EMS. The City of Cape May EMS reserves the right to remove accounts which were originally placed.

9.12 Provider must agree that any lawsuits incurred as a result of handling City of Cape May EMS accounts will not be the responsibility of City of Cape May and shall indemnify City of Cape May accordingly.

9.13 At a minimum the City will provide the following information to the provider for each debtor:

9.13.1 Patients name and or guarantor if different than the person who received the services

9.13.2 Last known address and phone number

9.13.3 Social Security number and or Federal ID number on record

9.13.4 Amount due

9.13.5 Date of Service

9.13.6 Provider must make available via a secure website, a monthly activity report of all account balances to City of Cape May EMS, which will be due no later than the fifteenth of each month for the prior months’ activity. Reports should reflect the following minimum information:

9.13.7 Patient name

9.13.8 Account number

9.13.9 Date and dollar amount submitted to collection firm

9.13.10 Number of customer contacts and type of contacts made (phone, mail). At its discretion, City of Cape Maymay request copies of contact verification via audit trails from the collection firm.

9.13.11 Collection fee per account

9.13.12 Monthly payments arranged with patient

9.13.13 Balance due

9.14 Completed accounts reports shall reflect the following information:

9.14.1 Patient name

9.14.2 Date and dollar amount submitted to the collection agency

9.14.3 Firm collection fee per account

9.14.4 Total dollars collected

9.14.5 Firms’ total payment based on assessed collections percentage

9.14.6 The payment of fees by the City of Cape May is contingent upon collection. There shall be no payment paid on any account on which collection was not made.

9.14.7 The provider shall place all accounts on the National Credit Report within 45 days of no activity by the patient and shall remain on the report until the account is paid in full or seven (7) years; it shall only be removed with written permission from City of Cape May

EMS.

9.14.8 The provider must be available for quarterly meetings with City of Cape May EMS personnel to discuss billing and collection issues.

9.14.9 The provider must maintain a professional and open line of communication with personnel from City of Cape May EMS.

The provider shall abide by all HIPAA rules that are in place and have the ability to conform to and comply with future changes. Submit documentation reflecting compliance with provisions of HIPAA HITECH in accordance with the American Recover and Reinvestment Act of 2009

Technical criteria: RATER NAME:

(Max Points _) 1 Pt = Poor Response, 3 Points = Average Response, 5 Pts =

Concise and Superior Response

Vendor Name:

(1) Does the vendor's proposal demonstrate a clear understanding of the scope as listed in the minimum qualifications?

(2) Is the vendor's proposal complete and responsive to the specific requirements for service as requested?

(3) Has the past performance of the vendor's experience and qualifications been documented and proposed?

(4) Does the vendor's proposal use innovative technology and techniques that set them apart from other proposals?

Sub Total Technical 0

Management criteria:

(Max Points __) 1 Pt = Poor Response, 3 Points = Average Response, 5 Pts =

Concise and Superior Response

Vendor Name:

(1)How well does the proposed scheduling timeline meet the contracting unit's needs?

(2)Is there a project management plan?

(3)Does the vendor document the qualifications of its personnel to a greater degree of expertise than other proposals?

Sub Total Managerial 0

Cost criteria:

(Max Points __) 1 Pt = Poor Response, 3 Points = Average Response, 5 Pts =

Concise and Superior Response

Vendor Name:

(1)How well does the proposed scheduling timeline meet the contracting unit's needs?

(2)Is there a project management plan?

(3)Does the vendor document the qualifications of its personnel to a greater degree of expertise than other proposals?

(4) Yearly maintenance cost of software & data storage

SUB TOTAL COST 0

Final Rater Score 0

EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L.1975, c.127)

N.J.A.C. 17:27 et seq.

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination;

rates of pay or other forms of compensation; and selection for training, including apprenticeship.

The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27-5.2.

The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions.

The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

Letter of Federal Affirmative Action Plan Approval;

Certificate of Employee Information Report; or

Employee Information Report Form AA-302 (electronically provided by the Division and distributed to the public agency through the Division’s website at: http:// www.state.nj.us/treasury/contract_compliance.

The contractor and its subcontractors shall furnish such reports or other documents to the Division of Purchase & Property, CCAU, EEO Monitoring Program as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Purchase & Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27-1.1 et seq http://www.state.nj.us/treasury/contract_compliance

NEW JERSEY ANTI-DISCRIMINATION PROVISIONS

N.J.S.A. 10:2-1 ET SEQ.

Pursuant to N.J.S.A. 10:2-1, if awarded a contract, the contractor agrees that:

a. In the hiring of persons for the performance of work under this contract or any subcontract hereunder, or for the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under this contract, no contractor, nor any person acting on behalf of such contractor or subcontractor, shall, by reason of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex, discriminate against any person who is qualified and available to perform the work to which the employment relates;

b. No contractor, subcontractor, nor any person on his behalf shall, in any manner, discriminate against or intimidate any employee engaged in the performance of work under this contract or any subcontract hereunder, or engaged in the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under such contract, on account of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex;

c. There may be deducted from the amount payable to the contractor by the contracting public agency, under this contract, a penalty of $50.00 for each person for each calendar day during which such person is discriminated against or intimidated in violation of the provisions of the contract; and

d. This contract may be canceled or terminated by the contracting public agency, and all money due or to become due hereunder may be forfeited, for any violation of this section of the contract occurring after notice to the contractor from the contracting public agency of any prior violation of this section of the contract.

SAMPLE CERTIFICATE OF EMPLOYEE INFORMATION REPORT

New Jersey Business Registration Certification

Pursuant to N.J.S.A. 52:32-44, The City of Cape May (“Contracting

Agency”) is prohibited from entering into a contract with an entity unless the bidder/proposer/contractor, and each subcontractor that is required by law to be named in a bid/proposal/contract has a valid Business Registration

Certificate on file with the Division of Revenue and Enterprise Services within the

Department of the Treasury.

Prior to contract award or authorization, the contractor shall provide the

Contracting Agency with its proof of business registration and that of any named subcontractor(s).

Subcontractors named in a bid or other proposal shall provide proof of business registration to the bidder, who in turn, shall provide it to the Contracting Agency prior to the time a contract, purchase order, or other contracting document is awarded or authorized.

During the course of contract performance:

(1) the contractor shall not enter into a contract with a subcontractor unless the subcontractor first provides the contractor with a valid proof of business registration.

(2) the contractor shall maintain and submit to the Contracting Agency a list of subcontractors and their addresses that may be updated from time to time.

(3) the contractor and any subcontractor providing goods or performing services under the contract, and each of their affiliates, shall collect and remit to the Director of the Division of Taxation in the Department of the

Treasury, the use tax due pursuant to the Sales and Use Tax Act, (N.J.S.A.

54:32B-1 et seq.) on all sales of tangible personal property delivered into the State. Any questions in this regard can be directed to the Division of

Taxation at (609)292-6400. Form NJ-REG can be filed online at http://www.state.nj.us/treasury/revenue/busregcert.shtml.

Before final payment is made under the contract, the contractor shall submit to the Contracting Agency a complete and accurate list of all subcontractors used and their addresses.

Pursuant to N.J.S.A. 54:49-4.1, a business organization that fails to provide a copy of a business registration as required, or that provides false business registration information, shall be liable for a penalty of $25 for each day of violation, not to exceed $50,000, for each proof of business registration not properly provided under a contract with a contracting agency.

Emergency Purchases or Contracts

For purchases of an emergent nature, the contractor shall provide its Business

Registration Certificate within two weeks from the date of purchase or execution of the contract or prior to payment for goods or services, whichever is earlier.

http://www.state.nj.us/treasury/revenue/busregcert.shtml

SAMPLE BUSINESS REGISTRATION CERTIFICATE

FormAA302 Rev. 11/11

PAY TO PLAY ADVISORY

Disclosure Requirement

P.L. 2005, Chapter 271, Section 3 Reporting

(N.J.S.A. 19:44A – 20.27)

Any business entity that has received $50,000 or more in contracts from government entities in a calendar year will be required to file an annual disclosure report with ELEC.

The report will include certain contributions and contract information for the current calendar year.

At a minimum, a list of all business entities that file an annual disclosure report will be listed on ELEC’s website at www.elec.state.nj.us.

If you have any questions please contact ELEC at:

1-888-313-ELEC (toll free in NJ) or

609-292-8700

An analyst from ELEC’s Special Programs Section will assist you.

Initials http://www.elec.state.nj.us/

Experience & Qualifications Questionnaire

This questionnaire must be filled out and submitted as a part of the Proposal.

Failure to complete this form or to provide any of the requested information will be grounds for the rejection of the bid proposal. If additional space is required, the respondent shall add additional sheets, which identify the question being answered.

Number of years in business under present name & address:

If less than 5 years, list previous names and address:

Within the last 5 years has the business or any officer/partner failed to complete a contract awarded to them: . If yes, provide the details in on a separate page.

Have any liens and lawsuits been filed against the company in the past 5 years:

If yes, please provide details:

List similar services you are now providing for which you have signed contract, but not yet started work:

List all major subcontractors to be used to complete the service and the area of their responsibility:

Experience & Qualifications Questionnaire

Please provide at least 3 references below:

Name: Phone:

Address:

Equipment/Service Provided:

Contract Amount:

Americans with Disabilities Act of 1990

The CONTRACTOR and the OWNER do hereby agree that the provisions of Title 11 of the Americans With

Disabilities Act of 1990 (the "ACT") (42 U.S.C~ S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any act benefit, or service on behalf of the OWNER pursuant to this contract, the CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event that the Contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the CONTRACTOR shall defend the OWNER in any action or administrative proceeding commenced pursuant to this Act. The Contractor shall indemnify, protect, and save harmless the OWNER, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the OWNER grievance procedure, the CONTRACTOR agrees to abide by any decision of the OWNER which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the OWNER or if the OWNER must any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its OWN expense.

The OWNER shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with frill and complete particulars of the claim. if any action or administrative proceedings is brought against the OWNER or any of its agents, servants, and employees, the OWNER shall expeditiously forward or have forwarded to the CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the OWNER or its representatives.

It is expressly agreed and understood that any approval by the OWNER of the services provided by the

CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the OWNER pursuant to this paragraph.

It is further agreed and understood that the OWNER assumes no obligation to indemnify or save harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the CONTRACTOR'S obligations assumed in this Agreement, nor shall they be construed to relieve the CONTRACTOR from any liability, nor preclude the OWNER from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor’s obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

Business Name (Print):

Representative’s Name (Print):

Representative’s Title:

Representative’s Signature:

Phone: Date:

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal.

Name of Organization:

Organization Address:

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

Partnership Limited Partnership Limited Liability Partnership (LLP)

Other (be specific):

Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE

THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS

OR LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed.

Stockholder/Partner/Member and Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the City is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with City to notify the City in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the City to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print):

Title:

Signature:

Date:

Part 2: Additional Information

Disclosure of Investment Activities in Iran

Person or Entity

Part 1: Certification

COMPLETE PART 1 BY CHECKING EITHER BOX.

Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate is identified on the State Department of Treasury's

Chapter 25 list as a person or entity engaging in investment activities in Iran. The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.

The Chapter 25 list must be reviewed prior to completing the below certification. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may provided by law, rule or contract, including but not limited to imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.

I certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the

Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below.

I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s Chapter

25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below.

http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf

PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN.

You must provide a detailed, accurate and precise description of the activities of the person or entity, or a parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below and, if more space is needed, on additional sheets provided by you.

Part 3: Certification of True and Complete Information

I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments there to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above-referenced person or entity.

I acknowledge that the City is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the

City to notify the City in writing of any changes to the answers of information contained herein.

I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the City and that the City at its option may declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print)

Title

Signature

Date

CERTIFICATION OF NON‐INVOLVEMENT IN PROHIBITED

ACTIVITIES IN RUSSIA OR BELARUS

Pursuant to N.J.S.A. 52:32-60.1, et seq. (L. 2022, c. 3) any person or entity (hereinafter “Vendori”) that seeks to enter into or renew a contract with a State agency for the provision of goods or services, or the purchase of bonds or other obligations, must complete the certification below indicating whether or not the Vendor is identified on the Office of

Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, available here:

https://sanctionssearch.ofac.treas.gov/. If the Department of the Treasury finds that a Vendor has made a certification in violation of the law, it shall take any action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.

I, the undersigned, certify that I have read the definition of “Vendor” below, and have reviewed the Office of Foreign

Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, and having done so certify:

(Check the Appropriate Box)

A.

That the Vendor is not identified on the OFAC Specially Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.

B. That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated

Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.

C.

That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated

Nationals and Blocked Persons list. However, the Vendor is engaged in activity related to Russia and/or Belarus consistent with federal law, regulation, license or exemption. A detailed description of how the Vendor’s activity related to Russia and/or Belarus is consistent with federal law is set forth below.

(Attach Additional Sheets If Necessary.)

Signature of Vendor’s Authorized Representative Date

Print Name and Title of Vendor’s Authorized Representative Vendor’s FEIN

Vendor’s Name Vendor’s Phone Number

Vendor’s Address (Street Address) Vendor’s Fax Number

Vendor’s Address (City/State/Zip Code) Vendor’s Email Address https://pub.njleg.state.nj.us/Bills/2022/PL22/3_.PDF https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ i Vendor means: (1) A natural person, corporation, company, limited partnership, limited liability partnership, limited liability company, business association, sole proprietorship, joint venture, partnership, society, trust, or any other nongovernmental entity, organization, or group; (2) Any governmental entity or instrumentality of a government, including a multilateral development institution, as defined in Section 1701(c)(3) of the

International Financial Institutions Act, 22 U.S.C. 262r(c)(3); or (3) Any parent, successor, subunit, direct or indirect subsidiary, or any entity under common ownership or control with, any entity described in paragraph (1) or (2).

NJ Rev. 1.22.2024

NON COLLUSION

STATE OF NEW JERSEY

City of Cape May

I certify that I am _______________________________________________________________ of the firm of __________________________________________________________________ the Respondent making this Proposal for the bid or proposal for the above named project, that I executed the said proposal with full authority to do so; that said bidder has not, directly or indirectly entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free, competitive bidding in connection with the above named project; and that all statements contained in said proposal and this affidavit are true, correct, and made with full knowledge that the City of Cape May relies upon the truth of the statements contained in said Proposals and in the statements contained in this affidavit in awarding the contract for the said project.

I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee, except bona fide employees or bona fide established commercial or selling agencies.

Signature of Representative:

Subscribed and sworn to before me this_________ day of ___________________, 20_______

Print Name of Affiant:___________________________________________________________

Notary Public of ____________________________

My commission expires_______________________

*This form MUST be completed, notarized and submitted with the bid document*