ESBD_518367_1779289431610_26-4090-09 RFP EMPLOYEE HEALTH INSURANCE.pdf

RFP Documents for

Employee Health Insurance

Burnet County, Texas

RFP # 26-4090-09

DEADLINE FOR QUESTIONS: MAY 29, 2026

12:00 PM

DUE DATE/TIME: JUNE 10, 2026, 10:00 AM

RFP 26-4090-09 EMPLOYEE HEALTH INSURANCE

REQUEST FOR PROPOSALS (RFP) FOR EMPLOYEE HEALTH

INSURANCE

RFP NO. 26-4090-09: Employee Health Insurance

ISSUANCE DATE: May 20, 2026

QUESTION DEADLINE: May 29, 2026, submit to bids@burnetcountytexas.org

SUBMISSION DEADLINE: June 10, 2026, at 10:00 AM (CST)

SUBMISSION LOCATION: Burnet County Auditor’s Office 133 E. Jackson, Burnet, TX 78611

WAYS TO SUBMIT: bids@burnetcountytexas.org or dropped off/mailed to Burnet County Auditor’s Office: 133 E. Jackson, Burnet, TX 78611

POINT OF CONTACT: Megan Schumann

Purchasing Agent Email: bids@burnetcountytexas.org Phone: (512) 756-5412

1.Notice of Request for Proposals

Burnet County is soliciting sealed proposals from qualified insurance carriers, third-party administrators (TPA’s), employee benefits consultants, and/or brokers for the provision of employee health insurance for county employees and eligible dependents.

The County seeks proposals that provide competitive pricing, comprehensive coverage, strong provider networks, administrative efficiency, compliance support, and excellent customer service.

This RFP is being issued to explore the Counties options. There may not be a contract following submittals and review.

2. Scope of Services

Proposers may submit for one or more of the following:

Medical Insurance

• Fully insured and/or self-funded options

• PPO, HDHP, HAS-compatible plans

• Prescription drug coverage

• Preventative care

• Telehealth services

• Wellness programs

• Disease management

• Employee Assistance Program (EAP) mailto:bids@burnetcountytexas.org

Dental Insurance

• Preventive

• Basic and major services

• Orthodontics

Vision Insurance

• Exams

• Lenses/frames

• Contact lens allowance

Administrative Services

• Enrollment support

• COBRA administration

• ACA compliance support

• HIPPA compliance

• Claims reporting

• Renewal strategy

• Employee education and enrollment meetings

3. Current Plan Information

See attachment.

4. Minimum Qualifications

Proposers must:

• Be licensed to do business in Texas

• Maintain all required state and federal licenses

• Have a minimum of five (5) years experience with Texas governmental entities

• Provide at least three (3) county government references

• Provide proof of required insurance coverage

5. Required Insurance

Vendor shall maintain

General Liability

$1,000,000.00 per occurrence

$2,000,000.00 aggregate

Professional Liability/Errors & Omissions

$2,000,000.00 per claim

Cyber Liability

$1,000,000.00 minimum

Workers Compensation

Statutory limits

6. Proposal Requirements

Proposals shall include:

A. Company Information

• Legal name

• Address

• Contact person

• Years in business

• Ownership structure

B. Executive Summary C. Proposed Coverage Options

Detailed plan designs including:

• Premiums

• Deductibles

• Copays

• Coinsurance

• Out-of-pocket maximums

• Network information

D. Claims and Administrative Services Explain:

• Claims turnaround

• Customer service

• Technology platforms

• Enrollment system

E. Cost Proposal Provide:

• Monthly premiums

• PEPM fees

• Broker compensation disclosure

• Administrative fees

• Renewal guarantees

• Rate guarantees

7. Evaluation Criteria

Proposals will be evaluated based on:

Criteria Weight Cost/Premium Structure 35% Plan Design/Coverage Options 25% Experience with Counties 15% Service & Administrative Support 15% References 10%

8. Contract Terms

Contract term:

Initial three (3) year agreement with two (2) optional one-year renewals, subject to Commissioners Court approval.

The County reserves the right to terminate for convenience with thirty (30) days written notice.

9. Reservation of Rights

The County reserves the right to:

• Reject any or all proposals

• Waive informalities

• Negotiate with proposers

• Request additional information

• Cancel the RFP

• Award in the best interest of the County

10. Selection Process

• Review: The Selection Committee will review and preliminarily score all responsive SOPs.

• Shortlist (Optional): The Commissioners Court reserves the right to shortlist the top-ranked respondents and conduct interviews.

• Ranking: The Commissioners Court will rank the Respondents in order of qualification based on its own independent review of the responsive SOPs. Final scoring and ranking will occur after the interview process, if any, and will be scored by the Commissioners Court at their sole discretion.

• Negotiation: IN accordance with Texas Government Code Sec. 2254.003 the County will attempt to negotiate a fair and reasonable price with the highest-ranked firm.

o If a satisfactory contract cannot be negotiated with the most highly qualified provider, the County will formally end negotiations with that provider and attempt to negotiate with the next most highly qualified provider.

o This process will continue until a contract is entered into or the County rejects all proposals.

• Approval: The final contract must be approved by the Burnet County Commissioners Court.

Documents are to be submitted as outlined in this RFP. The remaining documents are for the information of the RESPONDENT and will form the Contract Documents between the successful RESPONDENT and the OWNER.

LEGAL NAME OF CONTRACTING COMPANY

CONTACT NAME TITLE

MAILING ADDRESS E-MAIL ADDRESS

CITY STATE ZIP CODE

PHONE NUMBER FAX NUMBER

SIGNATURE PRINT SIGNATURE

The undersigned acknowledges receipt of the following addenda:

Addendum No. 1 dated _________________ Received ______________________ Addendum No. 2 dated _________________ Received ______________________ Addendum No. 3 dated _________________ Received ______________________

THIS FORM MUST BE SIGNED AND RETURNED WITH YOUR RFP

CIQ Page 1 of 2

THIS FORM MUST BE SIGNED AND THE ORIGINAL RETURNED WITH RFP RESPONSE

CIQ Page 2 of 2

BURNET COUNTY

RESPONDENT AFFIRMATION

This sheet must be completed, signed, and returned by RESPONDENT

NOTE: FAILURE TO SIGN AND RETURN THIS FORM WITH THE RFP DOCUMENT

MAY RESULT IN THE RFP BEING REJECTED OR THE TERMINATION OF

ANY RESULTING CONTRACT OR PURCHASE ORDER.

1. The undersigned agrees this RFP becomes the property of Burnet County after the official opening.

The undersigned affirms he has familiarized himself with the local conditions under which the work is to be performed; satisfied himself of the conditions of delivery, handling and storage of equipment and all other matters which may be incidental to the work, before submitting a RFP.

The undersigned agrees, if this RFP is accepted, to furnish any and all items/services upon which prices are offered, at the price(s) and upon the terms and conditions contained in the Specifications. The period for acceptance of this RFP Proposal will be sixty (60) calendar days unless a different period is noted by the RESPONDENT.

2. RESPONDENT affirms that they are duly authorized to execute this Contract, that this company, corporation, firm, partnership or individual has not prepared this RFP in collusion with any other RESPONDENT, and that the contents of this RFP as to prices, terms or conditions of said RFP have not been communicated by the undersigned nor by any employee or director to any other person engaged in this type of business prior to the official opening of this RFP.

3. RESPONDENT hereby assigns to purchaser any and all claims for overcharges associated with this Contract which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq.

4. Pursuant to §262.076 (a) of the Texas Local Government Code, RESPONDENT, hereby affirms that RESPONDENT:

(Please check all that are applicable)

______ Does not own taxable property in Burnet County.

______ Does not owe any ad valorem taxes to Burnet County or is not otherwise indebted to Burnet County.

RESPONDENT Affirmation Page 1 of 2

RESPONDENT AFFIRMATION

The undersigned affirms that they have read and do understand the specifications, addendum, RFP forms and any attachments contained in this RFP package. Failure to sign and return this form will result in the rejection of the entire RFP.

RESPONDENT COMPANY NAME

ADDRESS

CITY STATE ZIP CODE

PHONE EMAIL

RESPONDENT SIGNATURE DATE

RESPONDENT PRINTED NAME TITLE

SIGNATURE OF COMPANY OFFICIAL DATE

AUTHORIZING THE RFP (If Applicable)

COMPANY OFFICIAL PRINTED NAME TITLE

Corporate Vendors Shall Furnish the Following Information:

WHERE INCORPORATED CHARTER NUMBER

BUSINESS INCLUDED IN A CORPORATE INCOME TAX RETURN? _______YES _______NO

CORPORATION ORGANIZED & EXISTING UNDER THE LAWS OF THE STATE OF________

PARTNERSHIP CONSISTING OF ________________________________________________

INDIVIDUAL TRADING AS ______________________________________________________

PRINCIPLE OFFICES ARE IN THE CITY OF ________________________________________

RESPONDENT Affirmation Page 2 of 2

NON-COLLUSION/ANTI-TRUST AFFIDAVIT

The Company has not given, offered to give, nor intends to give at any time hereafter, any economic opportunity, future employment, gift, loan gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted response. Failure to sign this document or signing it with a false statement shall void the submitted offer or any resulting contracts.

Neither the Company or the firm, corporation, partnership, or institution represented by the Company or anyone acting for such firm, corporation, or institution has violated the antitrust laws of this State, codified in Section 15.01, et seq., Texas Business and Commerce Code, or the Federal antitrust laws, nor communicated directly or indirectly the offer made to any competitor or any other person engaged in such line of business. The Company’s signature herein assigns to the County any and all claims for overcharges associated with his contract for this project, which arise under the Antitrust Laws of the United States, 15 USCA, Section 1, Et. Seq. (1973). By signing this proposal, Company certifies that if a Texas address is shown as its address, Company qualifies as a Texas Resident RESPONDENT as defined in Rule 1 TAC 111.2.

RESPECTFULLY SUBMITTED:

AUTHORIZED SIGNATURE

PRINTED NAME

TITLE

COMPANY NAME

COMPANY’S CORPORATE CHARTER NO.

TAX RECORD AND FAMILY CODE REQUIREMENTS

The Company's signature herein certifies that the firm is not currently delinquent in the payment of any debt owed to the State of Texas; including but not limited to franchise taxes and child support, property tax, and that any payments due the firm under this contract will be applied to that debt.

Texas Family Code Compliance Requirement:

Under Section 231.006, Family Code, the vendor or applicant certifies that the individual or business entity named in this contract, RFP, or application is not ineligible to receive the specified grant, loan, or payment and acknowledges that this contract may be terminated, and payment may be withheld if this certification is inaccurate. The response includes the names and Social Security Numbers of each person with a minimum of twenty-five percent (25%) ownership of the business entity submitting the response.

Firm Owner(s), Partners, Sole Proprietors, or Share Holder(s) of twenty-five percent (25%) interest:

NAME SSN

NAME SSN

NAME SSN

NAME SSN

RESPECTFULLY SUBMITTED:

AUTHORIZED SIGNATURE

PRINTED NAME

TITLE

COMPANY NAME

COMPANY’S CORPORATE CHARTER NO.

VENDOR REFERENCE INFORMATION SHEET

Please list three (3) references, other than Burnet County, who can verify your performance as a vendor. Performance includes but shall not be limited to, sales and/or service, delivery, invoicing, and other items as may be required for Burnet County to determine your firm’s ability to provide the intended goods or services of this RFP. The County prefers references to be from customers for whom your firm has provided the same items (sales and/or services) as those specified in this RFP. Inaccurate, obsolete or negative responses from the listed references could result in rejection of your RFP. County reserves the right to reject RFPs from RESPONDENTs without experience similar to that provided in this RFP document.

1. _____________________________________________________________________

GOVERNMENT ENTITY/COMPANY NAME

ADDRESS PHONE

CONTACT PERSON TITLE

EMAIL ADDRESS (PRIMARY) EMAIL ADDRESS (SECONDARY)

SCOPE OF WORK

CONTRACT PERIOD

2. _____________________________________________________________________

GOVERNMENT ENTITY/COMPANY NAME

ADDRESS PHONE

CONTACT PERSON TITLE

EMAIL ADDRESS (PRIMARY) EMAIL ADDRESS (SECONDARY)

SCOPE OF WORK

3. _____________________________________________________________________

GOVERNMENT ENTITY/COMPANY NAME

ADDRESS PHONE

CONTACT PERSON TITLE

EMAIL ADDRESS (PRIMARY) EMAIL ADDRESS (SECONDARY)

SCOPE OF WORK

This Form must be SIGNED and the Original Returned with RFP response

CERTFICATE OF ELIGIBILITY

By submitting a RFP or proposal I response to this solicitation, the RESPONDENT/proposer certifies that at the time of submission, he/she is not on the Federal Government’s list of suspended, ineligible, or debarred contractors.

In the event of placement on the list between the time of RFP/proposal submission and time of award, the RESPONDENT/ proposer will notify the Burnet County Purchasing Agent. Failure to do may result in terminating this contract for default.

AUTHORIZED SIGNATURE DATE

PRINT NAME

VENDOR COMPLIANCE WITH RECIPROCITY ON NON-RESIDENT

RESPONDENTS

Government Code 2252.002 provides that, in order to be awarded a contract as low RESPONDENT, a non-resident RESPONDENT must submit projects for construction, improvements, supplies or services in Texas at an amount lower than the lowest Texas resident RESPONDENT by the same amount that a Texas resident RESPONDENT would be required to under RFP a non-resident RESPONDENT in order to obtain a comparable contract in the state in which the non-resident’s principal place of business is located. A non-resident RESPONDENT is a contractor whose corporate offices or principal place of business is outside of the state of Texas.

This requirement does not apply to a contract involving Federal funds. The appropriate blanks in Section A must be filled out by all out-of-state or non-resident RESPONDENTs in order for your RFP to meet specifications. The failure of out-of-state or non-resident contractors to do so will automatically disqualify that RESPONDENT. Resident RESPONDENTs must check the blank in Section B.

A. Non-resident vendors in ________________________(give state), our principal place of business, are required to be __________ percent lower than resident RESPONDENTs by state law. A copy of the statute is attached.

Non-resident vendors in ______________________(give state), our principal place of business, are not required to under RFP resident RESPONDENTs.

B. Our principal place of business or corporate offices are in the State of Texas: ________.

RESPONDENT:

COMPANY NAME

CITY STATE ZIP CODE

PRINTED NAME

AUTHORIZED SIGNATURE

TITLE

HISTORICALLY UNDERUTILIZED BUSINESSES (HUB) POLICY

I. POLICY STATEMENT

The Burnet County Commissioners Court, being the policy development and budgetary control unit of county government, will strive to ensure that all businesses, regardless of size, economic, social or ethnic status have an equal opportunity to participate in the County’s procurement processes. The County is committed to promote full and equal business opportunity for all businesses to supply the goods and services needed to support the mission and operations of county government, and seeks to encourage the use of certified historically underutilized businesses (HUBs) through the use of race, ethnic and gender neutral means. It is the policy of Burnet County to involve certified HUBs to the greatest extent feasible in the County’s procurement of goods, equipment, services and construction projects while maintaining competition and quality of work standards. The County affirms the good faith efforts of firms who recognize and practice similar business standards.

II. DEFINITIONS

Historically Underutilized Businesses (HUBs), also known as a disadvantaged business enterprise (DBE), are generally business enterprises at least 51% of which is owned, and the management and daily business operations are controlled by one or more persons who is/are socially and economically disadvantaged because of his or her identification as a member of certain groups, including women, Black Americans, Mexican Americans and other Americans of Hispanic origin, Asian Americans and American Indians.

Certified HUBs includes business enterprises that meet the definition of a HUB and who meet the certification requirements of certification agencies recognized by Burnet County.

Businesses include firms, corporations, sole proprietorships, vendors, supplier’s contractors, subcontractors, professionals and other similar references when referring to a business that provides goods and/or services regardless of the commodity category.

Statutory RFP limit refers to the Texas Local Government Code provisions that require competive proposals for many items/services valued at greater than $100,000.

III. POLICY GUIDELINES

A. Burnet County, its contractors, their subcontractors and suppliers, as well as all vendors of goods, equipment and services shall not discriminate on the basis of race, color, creed, gender, age, religion, national origin, citizenship, mental or physical disability, veteran’s status or political affiliation in the award and/or performance of contracts. All entities doing business or anticipating doing business with County shall support, encourage and implement affirmative steps toward a common goal of establishing equal opportunity for all citizens and businesses of the County.

B. Burnet County will use and recognize the State of Texas Historically Underutilized Business certification process in conjunction with the implementation of this policy.

The County may recognize other agencies’ certification processes recognized by the State of Texas. Burnet County reserves the right to review the certification status of any vendor applying to do business with the County. The review will be accomplished to determine the validity and authenticity of the vendor’s certification as a HUB.

C. The Commissioners Court may establish HUB target goals. Through a systematic approach of soliciting quotes, RFPs and proposals from certified HUBs and in compliance with applicable state and federal law this policy will strive to meet those goals.

1. Target goals should consider:

a. The availability of HUB firms within the specific category of goods or services to be procured; and

b. The diversity of the County’s population.

2. The goals should be reviewed and amended periodically.

3. The program may apply to all County procurements including construction and professional services.

4. Particular attention will be given to HUB participation on purchases in excess of the statutory RFP limit.

5. Commissioners Court will use good faith efforts to meet the goals of this policy.

D. Burnet County will actively seek and encourage HUBs to participate in all facets of the procurement process by:

1. Utilizing the State of Texas Historically Underutilized Business vendor database.

2. Advertising RFPs on the County’s website and in the local newspaper.

3. Providing RFP notice to minority Chambers of Commerce within Burnet County, if applicable.

E. As prescribed by law, the purchase of one or more items costing in excess of the statutory RFP limit must comply with the competitive RFP process. Where possible, those RFPs will be structured to include and encourage the participation of HUB firms in the procurement process.

F. A HUB Policy statement shall be included in all specifications. The County will consider the RESPONDENT’s responsiveness to the HUB Policy in the evaluation of RFPs and proposals. Failure to demonstrate a good faith effort to comply with the County’s HUB policy may result in a RFP or proposal being considered non-responsive to specifications.

G. The Purchasing Department will actively search the State Comptroller’s HUB vendor list in the quotation process for purchases under the statutory RFP limit.

H. Nothing in this policy shall be construed to require the County to award a contract other than to the lowest responsive RESPONDENT as required by law. This policy is narrowly tailored in accordance with applicable law.

IV. ADMINISTRATIVE GUIDELINES

A. The Purchasing Office shall serve as the County’s HUB Office with responsibility for the implementation, monitoring and general operations of the HUB policy. The Purchasing Director shall serve as the County HUB Officer.

1. The HUB Officer will establish procedures to implement this policy across the full spectrum of the procurement process. The County HUB Office will periodically review with department head and elected officials regarding procurement opportunities.

2. Managing the policy and training buyers and other County personnel in order to meet County goals will be the responsibility of the HUB Office.

3. The HUB Office will cooperate with other local government entities to increase HUB participation throughout the county and region. The HUB Office is encouraged to participate in educational and other outreach programs to assist HUB firms.

4. Any complaints and/or recommendations regarding the implementation of this policy will be received and reviewed by the HUB Officer. Further, the HUB Office will audit for compliance to the HUB Policy on eligible projects after award, during the performance of the contract and after completion, while also making any recommendations to Commissioner's Court regarding any irregularities or misrepresentations of facts as they relate to compliance with the policy. The HUB Office will review documentation submitted by HUB firms in compliance with this policy.

FOR DISADVANTAGED BUSINESS ENTERPRISES ONLY

Disadvantaged Business Enterprises (DBE) are encouraged to participate in Burnet County’s RFP process. The Purchasing Office will provide additional clarification of specifications, assistance with RFP Proposal Forms, and further explanation of responding/submittal procedures to those DBEs who request it.

Representatives from DBE companies should identify themselves as such and submit a copy of the Certification.

The County recognizes the certifications of the Texas Comptroller of Public Accounts Historically Underutilized Business Program. All companies seeking information concerning DBE certification are urged to contact The Texas Comptroller of Public Accounts at 800-531-5441, extension 3- 6958 or 512-463-6958.

If your company is already certified, attach a copy of your certification to this form and return with

RFP.

REPRESENTATIVE TITLE

ADDRESS

CITY STATE ZIP CODE

PHONE FAX

EMAIL ADDRESS (PRIMARY) EMAIL ADDRESS (SECONDARY)

Indicate all that apply:

______ Minority-Owned Business Enterprise

______ Women-Owned Business Enterprise

______ Disadvantaged Business Enterprise

CERTIFICATE OF INTERESTED PARTIES FORM 1295

Complete Nos. 1 - 4 and 6 if there are interested parties.

Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.

OFFICE USE ONLY

1 Name of business entity filing form, and the city, state and country of the business entity's place of business.

2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed.

3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract.

Name of Interested Party

City, State, Country (place of business)

Nature of Interest (check applicable)

Controlling Intermediary

5 Check only if there is NO Interested Party.

6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.

Signature of authorized agent of contracting business entity

AFFIX NOTARY STAMP / SEAL ABOVE

Sworn to and subscribed before me, by the said , this the day of , 20 , to certify which, witness my hand and seal of office.

Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath

Must file this form online at www.ethics.state.tx.us/File

Please include a printed copy of this notarized form with bid response.

http://www.ethics.state.tx.us/File

HOUSE BILL 89 VERIFICATION

NOTE: FAILURE TO SIGN AND RETURN THIS FORM WITH RFP RESPONSE MAY RESULT IN YOUR RFP BEING REJECTED

This verification must be completed, signed, and returned by RESPONDENT unless the business is a sole proprietorship or has less than 10 full time employees. Please sign and date below if you are exempt from this requirement.

1. I certify my business is a sole proprietorship or has less than 10 full-time employees.

DATE SIGNATURE OF COMPANY REPRESENTATIVE

If #1 is not applicable to your company, please move to #2 below.

2. I, ___________________________________(Name), the undersigned representative of (Company Name and Address)__________________________________________________ (hereafter referred to as Company) being an adult over the age of eighteen (18) years of age, after being duly sworn by the undersigned notary, do hereby depose and verify under oath that the company named-above, under the provisions of Subtitle F, Title 10, Government Code Chapter 2270:

1. Does not boycott Israel currently; and

2. Will not boycott Israel during the term of the contract the above-named

Company, business or individual with Burnet County, Texas.

Pursuant to Section 2270.001, Texas Government Code:

1. “Boycott Israel” means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli-controlled territory, but does not include an action made for ordinary business purposes; and

2. “Company” means a for-profit sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, or any limited liability company, including a wholly owned subsidiary, majority-owned subsidiary, parent company or affiliate of those entities or business associations that exist to make a profit.

DATE SIGNATURE OF COMPANY REPRESENTATIVE

On this, the _____ day of ___________________, 20____, personally appeared ________________________________________, the above-named person, who after by me being duly sworn, did swear and confirm that the above is true and correct.

NOTARY SEAL _____________________________

NOTARY SIGNATURE

FELONY CONVICTION NOTIFICATION

Any person and/or business entity that enters into a contract with the Burnet County must give advance notice if any employee or an owner or operator of the business entity has been convicted of a felony.

The notice must include a general description of the conduct resulting in the conviction of a felony.

The notice must also describe the role that the employee, owner, or operator will perform in executing the contract.

Burnet County may require substitution of employees in the performance of the contract. Burnet County may terminate a contract with a person or business entity if the County determines that the person or business entity failed to give notice as required by this clause, misrepresented the conduct resulting in the conviction, or failed to substitute personnel at the County’s request.

I, the undersigned agent for the firm named below, certify that the information concerning notification of felony convictions has been reviewed by me and the following information furnished is true to the best of my knowledge.

Signature of Authorized Company Official Date

Authorized Company Official’s Name and Title (Printed)

Firm Name

A. My firm is not owned or operated by anyone who has been convicted of a felony nor does it have any employees who have been convicted of a felony:

B. My firm has employee(s) or is owned or operated by the following individual(s) who has/have been convicted of a felony:

Person 1 Person 2

C. Provide a general description of the conduct resulting in the conviction of a felony.

Signature of Authorized Company Official Date

D. Describe the role that the person(s) convicted of a felony will play in the performance of the contract.

GC 2252.152 CERTIFICATION FORM

CONTRACTS WITH COMPANIES ENGAGED IN BUSINESS WITH IRAN,

SUDAN, OR FOREIGN TERRORIST ORGANIZATIONS PROHIBITED -

CERTIFICATION

I, _______________________________________________, the undersigned representative of

(Company or business name) being an adult over the age of eighteen (18) years of age, pursuant to Texas Government Code, Chapter 2252, Section 2252.152 and Section 2252.153, certify that the company named above is not listed on the website of the Comptroller of the State of Texas concerning the listing of companies that are identified under Section 806.051, Section

807.051 or Section 2253.153. I further certify that should the above-named company enter into a contract that is on said listing of companies on the website of the Comptroller of the State of Texas which do business with Iran, Sudan or any Foreign Terrorist Organization, I will immediately notify the Burnet County Purchasing Office.

SIGNATURE OF COMPANY REPRESENTATIVE

NAME OF COMPANY REPRESENTATIVE (PRINT)

TITLE

DATE

GC 2274 CERTIFICATION FORM

FIREARM ENTITIES AND TRADE ASSOCIATIONS

DISCRIMINATION CERTIFICATION

I, ___________________________________ the undersigned representative of

(Company or business name) being an adult over the age of eighteen (18) years of age, pursuant to Texas Government Code, Chapter 2274 verify that this company or business (1) does not have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association and (2) will not discriminate during the term of the contract against a firearm entity or firearm trade association. If Respondent does not make that verification, Respondent must indicate in its Response and state why the verification is not required.

APPLICABILITY: This clause applies only to a contract that:

(1) is between a governmental entity and a company with at least 10 full-time employees; and

(2) has a value of at least $100,000 that is paid wholly or partly from public funds of the governmental entity.

SIGNATURE OF COMPANY REPRESENTATIVE

NAME OF COMPANY REPRESENTATIVE (PRINT)

TITLE

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND

OTHER RESPONSIBILITY MATTERS

Offeror certifies to the best of its knowledge and belief that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal, State, or local department or agency.

2. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction: violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph 2 of this certification; and

4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default.

I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award.

COMPANY NAME

SIGNATURE OF COMPANY REPRESENTATIVE

NAME OF COMPANY REPRESENTATIVE (PRINT)

TITLE

_________ I am unable to certify the above statements. My explanation is attached.

RESERVATION OF RIGHTS

The County is issuing this RFP in accordance with applicable laws that allow an agreement with a private entity that displays demonstrated competence and PROPOSALS to perform the requested task.

The County reserves the right to terminate this process and to cancel or modify this solicitation process at any time. In no event will the County or any of its respective agents, representatives, consultants, directors, officers, or employees be liable for, or otherwise obligated to reimburse, the costs incurred in preparation of this RFP, or any other related costs. The prospective firms shall be fully responsible for all costs incurred in the preparation and/or presentation of the RFP submittals. The RFP submittals will become the property of the County.

All submissions shall be subject to the Texas Public Information Act unless the respondent clearly and prominently identifies a particular submittal item as proprietary and said item unequivocally qualifies for this exception under the Act as determined by the Attorney General.

In connection with the RFP, the County reserves all rights (which rights may be exercised by the County in its sole discretion) available to it under applicable laws, including without limitation, and with or without cause and with or without notice, the right to:

1. Cancel this RFP, in whole or in part, at any time before the execution of contract by the County, without incurring any cost, obligations or liabilities.

2. Issue addenda, supplements, and modifications to this RFP.

3. Revise and modify, at any time before the RFP submittal due date, the factors and/or weights of factors the County will consider in evaluating RFP submittals and to otherwise revise or expand its evaluation methodology as set forth herein.

4. Extend the RFP submittal due date.

5. Investigate the PROPOSALS of any firm under consideration and require confirmation of information furnished by a firm.

6. Require additional information from a firm concerning contents of its RFP submittal and/or require additional evidence of PROPOSALS.

7. Waive or permit corrections to data submitted with any response to this RFP until such time as the County declares, in writing, that a particular stage or phase of its review of the responses has been completed or closed.

8. Reject at any time, any or all submittals, responses and RFP submittals received.

9. Terminate, at any time, evaluations of responses received.

10. Appoint an evaluation committee to review RFP submittals or responses, make recommendations and seek the assistance of outside experts and consultants in RFP submittal evaluation.

11. Hold interviews and conduct discussions and correspondence with one or more of the firms responding to this RFP to seek an improved understanding and evaluation of the responses to this RFP.

12. Seek or obtain data from any source that has the potential to improve the understanding and evaluation of the responses to this RFP.

13. Disclose information contained in a RFP submittal to the public as required under the Texas Public Information Act.

14. Authorize firms to substitute key personnel until the County declares, in writing, that a particular stage or phase of its review has been completed and closed.

15. Waive deficiencies in a RFP submittal, accept and review a non-conforming RFP submittal or seek clarifications or supplements to a RFP submittal.

16. Disqualify any firm that changes its RFP submittal without the County’s authorization.

17. Exercise any other right reserved or afforded to the County under this RFP. The County reserves the right to modify the process, in its sole discretion, to address applicable law and/or the best interest of the County.

The County shall not, under any circumstances, be bound by or be liable for any obligations with respect to any services until such time (if at all) a contract has been awarded and all approvals obtained in form and substance satisfactory to the County have been executed and authorized by the County, and then only to the extent of such agreements.

SIGNATURE OF COMPANY REPRESENTATIVE

NAME OF COMPANY REPRESENTATIVE (PRINT)

TITLE

DATE

MAILING ADDRESS

CITY STATE ZIP CODE

SIGNATURE FORM

The undersigned, on behalf of and as the authorized representative of RESPONDENT, agrees this RFP becomes the property of Burnet County after the official opening.

The undersigned affirms that the RESPONDENT has familiarized himself with the local conditions under which the work is to be performed; satisfied himself of the conditions of delivery, handling and storage of equipment and all other matters that may be incidental to the work, before submitting a RFP.

The undersigned agrees, on behalf of RESPONDENT, that if the RFP is accepted, RESPONDENT will furnish all materials and services upon which price(s) are offered, at the price(s) and upon the terms and conditions contained in the specifications. The period for acceptance of this RFP will be sixty (60) calendar days.

The undersigned affirms that they are duly authorized to execute this contract, that this RFP has not been prepared in collusion with any other RESPONDENT, nor any employee of Burnet County, and that the contents of this RFP have not been communicated to any other RESPONDENT or to any employee of Burnet County prior to the official opening of this RFP.

Vendor hereby assigns to Burnet County all claims for overcharges associated with this contract which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq.

The undersigned affirms that they have read and do understand the specifications and any attachments contained in this solicitation. Failure to sign and return this form will result in the rejection of the entire RFP.

SIGNATURE OF COMPANY REPRESENTATIVE

NAME OF COMPANY REPRESENTATIVE (PRINT)

TITLE

STATEMENT OF NO RFP

If the RESPONDENT is not responding on the goods and/or services as stated in this RFP, please complete, and return this form to: Burnet County, Purchasing Office, 133 E. Jackson, Burnet, TX 78611.

CITY STATE ZIP CODE

SIGNATURE TITLE

DATE

EMAIL

The above has declined to submit a RFP response for the following reason(s) [please check all that apply]:

_____ Specifications too “restrictive,” i.e., goods offered by our company do not meet stated specifications.

_____ Specifications unclear (please explain below).

_____ We do not offer this commodity and/or service or an equivalent.

_____ Insufficient time to respond to the ITB.

_____ Our schedule would not permit us to perform.

_____ Cannot meet insurance requirements.

Remarks:

CERTIFICATE OF INSURANCE

The insurance evidenced by this Certificate shall conform to the Supplemental General Conditions, Section 5.3 Insurance:

Name and Address of Agency: County of Burnet Reference:

____________________________________ Project Name_________________________ ___________________________________________ Project No.:

Phone: ______/ _____________________ Project Location: ______________________

Name and Address of Insured:

_____________________ Companies Affording Coverages:

_____________________ Company A Phone: ______/ _____________________ Letter ______________ Company B Prime or Sub-Contractor?: ______________ Letter ______________ Company C Name of Prime Contractor, if different from Insured: Letter ______________ __________________________________________________ Company D Letter ______________

POLICY POLICY

EFFECTIVE EXPIRATION LIMITS OF

COMPANY TYPE OF POLICY DATE DATE LIABILITY IN

LETTER INSURANCE NUMBER (M/D/Y) (M/D/Y) THOUSANDS (000) EACH

Commercial General Liability

Policy

___Blanket Contractural

Liability General Aggregate $____________

___Completed Operations/

Products Completed Operations/

Products – Aggregate $____________

___Explosion, Collapse, Underground

Personal & Advertising Injury $____________

___Independent Contractor’s Coverage

Each Occurrence $____________

___Aggregate Limits Per

Project Form – CG 2503

___Additional Insured Form –CG 2010

___30 Day Notice of Cancellation Form – CG 0205

Deductible or Self Insured Retention $____________

___Waiver of Subrogation Form – CG 2404

___Transportation of

Asbestos or Lead

___Asbestos Abatement

___Lead Abatement

Certificate of Insurance

POLICY POLICY

EFFECTIVE EXPIRATION LIMITS OF

COMPANY TYPE OF POLICY DATE DATE LIABILITY IN

LETTER INSURANCE NUMBER (M/D/Y) (M/D/Y) THOUSANDS (000) EACH

Auto Liability Policy CSL

___Any Auto ___All Owned Autos Bodily Injury $____________

(Per Person)

___Non-Owned Autos

___Hired Autos Bodily Injury $____________ (Per Accident)

___Waiver of Subrogation-

TE2046A

Cancellation – TE0202A

Property Damage $____________ (Per Accident)

___Additional Insured-

TE9901B

___MCS 90 Deductible or Self Insured

Excess Liability

___Umbrella Form Each Aggregate Occurrence $____________

___Excess Liability Follow Form

Worker’s Compensation Statutory and Employers’ Liability

(Each Accident) $____________

___Waiver of (Disease - Policy Limit) $____________

Subrogation – WC420304 (Disease - Each Employee) $____________

Cancellation – WC420601

___Builders Risk or Installation Insurance

Professional Liability

Cancellation

Each Claim

Retro-Active Date:________________

Deductible or Self Insured

This is to certify that policies of insurance listed above have been issued to insured named above and are in force at this time. Notwithstanding any requirements, term or condition of any contract or other document with respect to which this certificate may be issued or may pertain, insurance afforded by policies described herein is subject to all terms, exclusions and conditions of such policies.

ADDITIONAL INSURED:

Burnet County 133 E. Jackson Burnet, Texas 78611

DATE ISSUED:__________ AUTHORIZED REPRESENTATIVE: ______________________

Did you sign and submit all required forms?

If not, your RFP may be Rejected!

AFFIRMATIONS/FORMS/DOCUMENTS

Indicates

Compliance

A check mark () in the space provided indicates these forms/documents have been completed and are included in your RFP package. The original of all forms/documents must be submitted. Failure to check all items could result in rejection of the entire RFP. All deviations from specifications must be documented separately and included with RFP package.

1. Vendor References. RESPONDENT has provided three (3) references, other than Burnet County. References must be able to verify the quality of service your company provides and that your company has completed a project of similar size and scope of work to this RFP.

2. Signatures. All forms, including certifications, affirmations and informational forms requiring a signature must be signed. RFPs not signed may not be considered for award.

3. RFP FORMS. All sections of RFP FORMS have been completed.

4. Insurance Certificates (If required). RESPONDENTs must submit all Insurance Certificates with RFP. If no insurance requirements specified, mark N/A.

5. Addenda. When applicable, RESPONDENT acknowledges receipt of all addenda and has included the signed Addenda cover pages and any revised RFP Forms in their RFP package.

6. It is the RESPONDENTS’ sole responsibility to print and review all pages of the RFP document, attachments, questions and their responses, addenda, and special notices.

7. Accuracy for all mathematical and number entries is the sole responsibility of the RESPONDENT. Burnet County will not be responsible for errors made by the RESPONDENT.

8. Failure to comply with the requirements set forth in this Invitation to RFP may result in rejection of RFP and/or cancellation of contract after award.

All Required Forms Must Be Returned With RFP!

RFP SUBMITTAL INSTRUCTIONS

RETURN SEALED RFP TO THE FOLLOWING ADDRESS:

BURNET COUNTY PURCHASING OFFICE

KELLEY GLAESER, PURCHASING AGENT

133 E. JACKSON

BURNET, TEXAS 78611

OR SUBMITTED ELECTRONICALLY TO:

bids@burnetcountytexas.org

LATE RFP’S WILL NOT BE ACCEPTED

BURNET COUNTY RETURN LABEL

SEALED INVITATION TO RFP

INVITATION TO RFP NO.: 26-4090-09

DUE DATE & TIME: JUNE 10, 2026, 10:00 AM CST

OPENING DATE & TIME: JUNE 10, 2026, 10:00 AM CST

DESCRIPTION: EMPLOYEE HEALTH INSURANCE

DATED MATERIAL – DELIVER IMMEDIATELY

PLEASE CUT OUT AND AFFIX THE ITB LABEL ABOVE TO

THE OUTER MOST ENVELOPE OF YOUR RESPONSE

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association HCR GF TAC Plan 1100 (10/01/2023) Page 1 of 4

BENEFIT HIGHLIGHTS

PLAN 1100

(HCR Grandfathered)

BLUECHOICE NETWORK

This is a general summary of your benefits. Please refer to your benefit booklet for additional details and a description of the plan requirements and benefit design. This plan does not cover all health care expenses. Upon receipt of your benefit booklet, carefully review the plan’s limitations and exclusions.

O v e r a l l P a y m e n t P r o v i s i o n s I n - N e t w o r k B e n e f i t s

O u t - o f - N e t w o r k B e n e f i t s

Plan Year Deductibles Per-admission Deductible $0 $0 Deductible Applies to all Eligible Expenses except Inpatient Hospital Expenses (unless otherwise indicated)

$750 Individual / $2,250 Family

$1,000 Individual / $3,000 Family

Plan Year Out-of-Pocket Maximum Deductibles are not applied to the Out-of-Pocket Maximum (OOPM).

Copayment Amounts will apply to the OOPM and will continue to be required after the maximum has been satisfied. Your benefit booklet will provide more details.

$3,000 Individual / $9,000 Family

$6,000 Individual / $18,000 Family

Network Deductible & Out-of-Pocket Maximum will only apply toward Network Deductible &

Out-of-Pocket Maximum

Out-of-Network Deductible & Out-of Pocket Maximum do not apply toward Network Deductible

& Out-of-Pocket Maximum

Copayment Amounts Required Physician office visit/consultation Refer to Medical/Surgical Expenses section for more information

$25 Copayment Amount N/A-Refer to Medical/Surgical Expense section for benefits

MDLIVE (Telemedicine)

Urgent Care

Outpatient Hospital Emergency Room/Treatment Room Refer to Emergency Room/Treatment Room section for more information

$0 Copayment Amount

$25 Copayment Amount

$120 Copayment Amount

Not Applicable

70% of Allowable Amount

$120 Copayment Amount

Maximum Lifetime Benefits Per Participant Unlimited

I n p a t i e n t H o s p i t a l E x p e n s e s Inpatient Hospital Expenses All services must be preauthorized

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units

80% of Allowable Amount 60% of Allowable Amount

Penalty for failure to preauthorize services None $250

Outpatient Hospital Emergency Refer to Emergency Room/Treatment Room section for more information

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association HCR GF TAC Plan 1100 (10/01/2023) Page 2 of 4

M e d i c a l / S u r g i c a l E x p e n s e s I n - N e t w o r k B e n e f i t s

O u t - o f - N e t w o r k B e n e f i t s

Medical / Surgical Expenses Services performed during the Physician’s office visit/consultation, including lab & x-ray (does not include Certain Diagnostic Procedures and surgical services)

100% of Allowable Amount after $25 Copayment Amount

70% of Allowable Amount after Plan Year Deductible

Lab & x-ray in other outpatient facilities (excluding Certain Diagnostic Procedures)

100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible

Allergy Injections 100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible

Colonoscopy (All places of treatment and diagnoses) 100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible

Physician surgical services performed in any setting 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

Certain Diagnostic Procedures; such as Bone Scan, Cardiac Stress Test, CT -Scan (with or without contrast), Ultrasound, MRI, Myelogram, PET Scan.

80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

Home Infusion Therapy (Services must be preauthorized) 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

Organ Transplants 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

All other outpatient services and supplies 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

In Vitro Fertilization Services Declined

E x t e n d e d C a r e E x p e n s e s Extended Care Expenses All services must be preauthorized

100% of Allowable Amount 70% of Allowable Amount after Plan Year Deductible

Skilled Nursing Facility 25 day maximum each Plan Year* Home Health Care 60 visit maximum each Plan Year* Hospice Care Unlimited

Special Provisions Expenses Serious Mental Illness All services must be preauthorized

Inpatient Services -Hospital services (facility) 80% of Allowable Amount 60% of Allowable Amount

-Physician services 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

Outpatient Services -Services performed during Physician office visit/consultation (does not include psychological testing)

100% of Allowable Amount after $25 Copayment Amount

70% of Allowable Amount after Plan Year Deductible

-All outpatient services and psychological testing 80% of Allowable Amount after Plan Year Deductible

60% of Allowable Amount after Plan Year Deductible

* Benefits used In-Network and Out-of-Network will apply toward satisfying any day, visit, Plan Year, Annual Maximum, series of treatments benefits shown.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association HCR GF TAC Plan 1100 (10/01/2023) Page 3 of 4

Special Provisions Expenses, cont. I n - N e t w o r k B e n e f i t s

O u t - o f - n e t w o r k B e n e f i t s

Mental Health Care/Chemical Dependency All services must be preauthorized. Inpatient treatment must be provided in a Chemical Dependency Treatment Center.

Inpatient Services -Hospital services (facility) 80% of Allowable Amount 60% of…