ESBD_File_344253_HHS0014286 CPA 6.2 Current Contractors OE Application (App 11-15).docx

6.2 CPA CURRENT CONTRACTOR RECERTIFICATION

OPEN ENROLLMENT 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 Attachments and Required Forms, File Folder 2 in Appendix A).

5. Contractor will submit all contract application files and documents to their assigned Residential Contract Manager by December 19, 2023.

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 Subsection 1.5.5 of this Open Enrollment, II(G) of Section 1.8.1(c), and I(G) of 6.3.1 and indicate in the table below if requirements are met.

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

Professional Liability Insurance or equivalent insurance if CPA intends to employ staff to provide professional services: |_|Yes |_|No

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

Business Automobile Liability (Owned & Hired Endorsements and Non-owned Auto): |_|Yes |_|No

If "No" is checked for any insurance named above, Contractor must submit insurance coverage documentation with the signed contract. DFPS will not execute a Contract if this documentation is not provided or is found to not meet the insurance requirements.

If “Yes” is checked for any insurance named above, Contractor must submit insurance coverage documentation prior to contract execution.

SECTION III – ORGANIZATION KEY MANAGEMENT

1. Attach a list of your CPA's Board of Directors (if applicable) including:

a. Full names;

b. Titles;

c. Addresses;

d. Email addresses; and

e. Phone numbers.

2. Attach a list of your CPA's Person(s) in a Key Position including:

a. Full names;

b. Titles, if applicable;

c. Addresses;

d. Email addresses; and

e. Phone numbers.

See definition of Person in a Key Position in the Requirements at https://www.dfps.texas.gov/Doing_Business/Purchased_Client_Services/Residential_Child_Care_Contracts/documents/24_Hour_RCC_Requirements.pdf.

SECTION V – 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)

APPENDIX A - APPLICATION, ATTACHMENTS, AND REQUIRED FORMS

FILE FOLDER 1:

Document Location Electronic File Name

Document Is Document Required Yes/No

DFPS CPA Current Contractor Recertification Application HHS0014286