Consultant Contractor Form.doc
DOC document 39 KB Posted
- Attached to
- NOI Providing Consulting Services to Assist in the Selection of a Life Insurance Carrier
- Solicitation number
- BD-15-1049-GIC00-07GIC-00000003561
- Issued by
- Suffolk County, Massachusetts
About this file
The document is a Consultant Contractor Mandatory Submission Form for the Commonwealth of Massachusetts Group Insurance Commission (GIC). It requires the bidder to disclose any additional income, persons with financial interest, and key personnel assigned to the contract. The GIC is seeking a consultant to provide project management, actuarial analysis, and technical assistance to develop a Request for Response (RFR) for a Life Insurance Carrier to provide services to the GIC's life insurance plans.
The RFR is titled "NOI Providing Consulting Services to Assist in the Selection of a Life Insurance Carrier" and has an unspecified response due date. The contract term is not provided. The form must be completed and signed by an authorized signatory for the bidder.
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Text version
Consultant Contractor Mandatory Submission Form
COMPLETE THE FOLLOWING ONLY FOR CONSULTANT CONTRACTS
(Within HH and NN and UU Object Classes)
Bidder: ________________________________________________________________________
RFR Name/Title: ________________________________________________________________
RFR Number: # _________________________________________________________________
Additional Income Disclosure. Pursuant to the provisions of M.G.L. c. 29, s. 29A, the following amounts represent any contracts, grants or other income due from the Commonwealth of Massachusetts, including any political subdivision or public authority, during the period of a contract. You may attach additional sheets as necessary.
FORMCHECKBOX
Please check if N/A.
Disclosure of Persons with Financial Interest (other than the bidder). Pursuant to the provisions of M.G.L. c. 29, s 29A and c. 7A, s. 6, the following individuals have a financial interest in a contract and/or with more than one percent (1%) interest in the capital stock of the contractor. You may attach additional sheets as necessary.
FORMCHECKBOX
Please check if N/A.
Key Personnel. Attach a resume or statement of qualifications for all key personnel specifically named in bidder's response to be assigned to the performance of a contract.
FORMCHECKBOX
Please check if N/A.
The information submitted herein is certified by the bidder to be accurate under the pains and penalties of perjury.
Signature of Authorized Signatory for Bidder: __________________________________________________
Title of Authorized Signatory for Bidder: _____________________________________________________
Date: __________________________________________________________
Updated 11/1/05
Sensitivity level - low
File details come from the government source that posted it. Updated .