ESBD_367425_1720549661768_5.2 Recertification Application.docx

5.2 SIL CURRENT CONTRACTOR RECERTIFICATION APPLICATION

INSTRUCTIONS

1. Contractor must read all of the Open Enrollment posted on the ESBD or HHS Enrollment Sites before completing this Application.

2. The Application must be completed and signed by the person authorized to sign the Contract in Section V (Certification) for it to be accepted by DFPS.

3. The Application must be complete for it to be accepted by DFPS. DFPS considers a complete answer to be a written response. Responding with “Not Applicable” is only an appropriate response when a question or form does not apply to the Contractor.

4. Contractor will provide the information in the body of the Application unless otherwise instructed to include it as an Attachment (See Open Enrollment documents).

5. Contractor will submit all contract application files and documents to their assigned Residential Contract Manager by July 31, 2024.

6. If DFPS has difficulty accessing the Contractor’s documents, the Contractor will be required to re-submit documents as directed by DFPS.

SECTION I – CONTRACTOR INFORMATION

SECTION II – INSURANCE

Review Sections 1.5.1(e), 1.6.2 (b), and 1.7.1(c) of the Open Enrollment, Section II(E) of DFPS Vendor Uniform Terms and Conditions, and Attachment 5.3 Special & Programmatic Conditions-SIL.

Indicate below that these requirements are met.

Commercial Crime Insurance or equivalent insurance with 3rd Party endorsement & Employee Dishonesty endorsement: |_|Yes |_|No

Commercial General Liability or equivalent insurance: |_|Yes |_|No

The Contractor must submit insurance coverage documentation for both types listed above with the signed application. DFPS will not execute a Contract if this documentation is not provided or is found to not meet the insurance requirements.

SECTION III – ORGANIZATION STAFF

Attach a list of all Staff employed at your operation including:

a. Full names;

b. Titles;

c. Addresses;

d. Email addresses; and

e. Phone numbers.

f. Date of last background check

SECTION IV – CERTIFICATION

I certify that the information provided in this Application is to the best of my knowledge, complete and accurate, that the named legal entity has authorized me, as its representative, to submit this Application, and that the legal entity complies with all requirements of this Open Enrollment.

I have informed DFPS of any changes to my information or documents previously submitted.

Name of Designated Signature Authority (Printed)

Title of Designated Signature Authority (Printed)

DFPS SIL Current Contractor Recertification Application