ESBD_File_347943_RFP11624 - Third Party Administrator - Workers Compensation.pdf

REQUEST FOR PROPOSAL

RFP No.11624

Third-Party Administrator - Worker's Compensation Claims - Repost

Southwest Key Programs

PROPOSAL SUBMISSION:

Procurement Department Southwest Key Programs

6002 Jain Lane Austin, Texas 78721

Bonfire SWK

REFER INQUIRIES TO:

Bonfire SWK

*To access proposal documents on Bonfire SWK, a free registration is required.

PROPOSALS ARE DUE: FRIDAY, FEBRUARY 2ND, 2024 BY 5:00 PM

TABLE OF CONTENTS

Table of Contents

1 INTRODUCTION AND OVERVIEW

1.1 Purpose of the Request for Proposal (“RFP”)

1.2 Background Information

1.3 Requirements and Deliverables

1.3.1 Overview

1.3.2 Solicitation Goals

1.3.3 Scope of Work

1.4 Samples

1.5 Subcontract Term/Option to Extend

1.6 Awarded Subcontracts

1.7 SWK Terms and Conditions

2 GENERAL INSTRUCTIONS AND STANDARD PROPOSAL REQUIREMENTS

2.1 Notice of Intent to Submit

2.2 Submission Of Questions

2.3 Proposal Submission, Date, and Time

2.4 Key Dates

2.5 Standard Proposal Requirements

2.6 Non-disclosure Agreements

2.7 Proposal Preparation Costs

2.8 Disclosure of Proposal Content

2.9 Vendors Conference

2.10 Conflict of Interests

3 PROPOSAL FORMAT AND CONTENT

3.1 Proposal Format and Content

3.1.1 Proposal Cover Page

3.1.2 Table of Contents

3.1.3 Response Checklist

3.2 Requirements Plan

3.3 Timelines

3.4 Cost Proposal

3.5 Respondent’s Profile and Financial Responsibility

3.6 Additional Terms and Conditions

4 REVIEW OF PROPOSALS

4.1 Review of Proposals

4.2 Selection Criteria

4.3 Discrimination

4.4 Encouraged Participants

4.5 Best and Final Offer

5 CONTRACTUAL REQUIREMENTS

5.1 Respondent’s Proposal

5.2 Material & Product Requirements

5.3 Vendor Performance

5.4 Payment

5.5 Vendor Registration in Oracle

6 Appendix

Attachment A – Terms and Conditions and Related Forms and Links

Attachment B – Notice of Intent to Submit a Proposal

Attachment C – Cover Page Suggested Format for Proposal

Attachment D – Respondent Company Profile Form

Attachment E – Respondent References Form

Attachment F – TPA Questionnaire

Attachment G – Additional Provisions

Attachment H – Program Locations

Attachment I – SWK Locations

Attachment J – Special Claims Handling Instructions

Attachment K - Cost proposal

1 INTRODUCTION AND OVERVIEW

1.1 PURPOSE OF THE REQUEST FOR PROPOSAL (“RFP”)

It is the intent of Southwest Key Programs, Inc. (“SWK”) to solicit proposals for a qualified and responsible entity to provide Third Party Administrator (TPA) services for Workers’ Compensation Claims.

1.2 BACKGROUND INFORMATION

SWK is a national nonprofit organization that exists to create opportunities and improve the quality of life for thousands of youth and families each day by providing safe shelter, alternatives to incarceration, career development and quality education. This is done through three areas of programming:

a. Immigrant Children’s Shelters

b. Youth and Family Services

c. Workforce Solutions

SWK supports each area of programming by our Corporate operations, located at headquarters and offices throughout several states.

1.3 REQUIREMENTS AND DELIVERABLES

1.3.1 Overview

SWK's current TPA relationship extends to Worker's Compensation claims only. The focus of the RFP is on the firm's ability to provide TPA services for Workers' Compensation claims; however, Respondents are encouraged to share commentary on how their firm would manage additional lines (i.e. commercial auto, property, general liability, etc.) of coverage should SWK's needs evolve. At present, SWK has operations in over 20 states and participates in a large deductible ($250,000 per claim) fully-insured workers' compensation program.

1.3.2 Solicitation Goals

This RFP aims to establish contact with a qualified TPA firm that provides Southwest Key Programs, Inc.

("SWK") and its subsidiary entities professional claims services. SWK intends that the selected TPA will start servicing TPA on all of SWK's Workers' Compensation claims tentatively effective January 31, 2024 (SWK reserves the right to update this date to align with the timelines stipulated within this RFP, as required).

1.3.3 Scope of Work

The successful TPA will be required to perform the general activities below and address program development, program management, program renewal, and additional services. The RFP aims to ensure SWK manages claims in the most efficient manner possible while providing the best service to its employees. The TPA is responsible for reporting and handling claims in compliance with state and federal regulations, and workers' compensation insurance carrier requirements. SWK welcomes proposals that include additional value-added services, including but not limited to unbundled or bundled workers' compensation program arrangements, claimant mobile phone application access (not required, but suggested), Medical Provider Networks (MPN’S), Occupational Safety and Health Administration (OSHA) 300 digital logs, data analytics, reporting, and loss forecasting. Fees for these services shall be fully disclosed on the proposal included in the cost proposal. Specific focus should be made on the following areas:

TPA will meet in-person with SWK at a location of the SWK's choosing at least quarterly to review the status and handling of all open claims and any other matters at the discretion of SWK

An annual stewardship meeting.

TPA shall allow SWK the opportunity to participate in regular training sessions or seminars held for its servicing personnel.

TPA shall supply a list of all potential servicing personnel with a current resume of each designated adjuster(s) who will handle SWK claims. It is preferred, that at least 50% of the claims adjuster assigned to the SWK account shall be bilingual in English and Spanish. Additional personnel involved in SWK claims handling should have a resume submitted for prior consultation with SWK

TPA shall specifically illustrate Special Investigation Unit (SIU) protocols, resources, and in-house SIU personnel (if any) that would be assigned to SWK's account.

Define the claim to adjuster ratio and if adjusters will be dedicated to the SWK account. In addition, ensure pricing models are defined by the various claim to adjuster ratios that the TPA is willing to offer (i.e., 100:1, 125:1, 150:1)

The proposal should include fees for the administration of all claims as of 01/31/24. Prior claim data may be integrated into the successful Respondent's claim system.

Provide a specific implementation plan and timeline, considering a start date of 01/31/2024 and outlining the potential takeover of existing open claims, as well as the conversion of claim data

SWK believes that, for an effective claims management program to be in place, there must be extensive interaction between SWK and the TPA. The successful Respondent must agree to comply with Special Claims Handling Instructions (See Attachment J). If the TPA's company standards are more stringent, those internal standards shall apply.

Describe how the Respondent plans to accomplish the Scope of Work; include internal controls for quality assurance by:

Provide a proposed project organizational chart, identifying reporting structure and areas of responsibility.

Describe previous similar services provided, including successes, failures, and lessons learned.

Provide report samples that demonstrate reporting capabilities of Risk Management Information

System (RMIS) system. Reports should show loss types, loss causes, frequency, severity, department losses, and coverage type losses.

Describe any additional value-added services including but not limited to claimant mobile phone application access, data analytics reporting, and loss forecasting.

Resumes of all key (Account Management) personnel who will be assigned to the project. (Limit to one (1) page maximum per resume.

Include a statement of each member's experience.

Identify this person's primary function(s) in terms of providing services under this contract.

Will this person be assigned to work under this contract exclusively?

If this person is not assigned to this contract exclusively, indicate the percentage of the time this person will be given to this contract.

The response should identify any subcontractor firms and the percentage of the effort assigned to the subcontractor. The response shall provide information on all subcontractors proposed as part of this contract, including:

(1) Company history

(2) Qualifications and experience

(3) Proposed staffing for this project

(4) Alliance relationship and length of the relationship

(5) Work with prior clients and descriptions of the specific projects

(6) Proposed staffing for the length of the agreement

Respondents must also include completed Attachment F - TPA Questionnaire within their proposal response.

Respondents are required to acknowledge and describe their capabilities to meet Attachment J –

Special Claims Handling Instructions. It is strongly recommended that these instructions are weaved within the process outlined within the proposal.

1.4 SAMPLES

Samples are not required for this Request for Proposal (RFP).

1.5 SUBCONTRACT TERM/OPTION TO EXTEND

The term of any subcontract resulting from this RFP shall be for one (1) fiscal year. SWK, at its own discretion, may extend any subcontract awarded pursuant to this RFP for up to two (2) additional fiscal years under the same or similar terms subject to appropriation of funds by SWK funders or the Office of Refugee Resettlement (“ORR”) for this project.

1.6 AWARDED SUBCONTRACTS

It is anticipated that one or multiple subcontract(s) will be awarded as a result of this RFP. Proposals must include a detailed cost proposal in accordance with the requirements of Section 3.4 of this RFP.

1.7 SWK TERMS AND CONDITIONS

By submitting a proposal, the Respondent is accepting SWK Terms and Conditions (https://southwestkey.org/procurement/). Any Respondent not accepting the SWK Terms and Conditions will be deemed non-responsive and not meeting the requirements of the RFP.

Appendix II to 45 CFR 75 - Contract Provisions for Non-Federal Entity Contracts Under Federal Awards shall also apply to this RFP. See Title 45 Part 75 Appendix II Code of Federal Regulations.

Respondent will also be required to adhere to all necessary Office of Refugee Resettlement (ORR) policies. Please see the ORR's Unaccompanied Children Program Policy Guide.

2 GENERAL INSTRUCTIONS AND STANDARD PROPOSAL

REQUIREMENTS

2.1 NOTICE OF INTENT TO SUBMIT

Respondent is encouraged to submit a letter of intent to Bonfire SWK if they intend to submit a proposal in response to this RFP; however Notice of Intent to Submit is optional. See Attachment B.

2.2 SUBMISSION OF QUESTIONS

Respondent questions shall be submitted to:

Bonfire SWK

2.3 PROPOSAL SUBMISSION, DATE, AND TIME

WITHOUT EXCEPTION – PROPOSALS MUST BE RECEIVED ON OR BEFORE:

FRIDAY, FEBRUARY 2ND, 2024 BY 5:00 PM CST

Proposals must reference the RFP number and be submitted to Bonfire SWK by the Respondent’s point-of-contact. PROPOSALS RECEIVED AFTER THE DUE DATE WILL NOT BE CONSIDERED.

2.4 KEY DATES

DATE EVENT

1/16/2024 Publication of Request for Proposal 1/22/2024 Optional Notice of Intent to Submit a Proposal 1/22/2024 Submission of Written Questions 1/26/2024 SWK Written Response to Questions 2/2/2024 Respondent Proposal Submission February 2024 Proposal Evaluation, Oral Presentations (if required), and

Negotiations (if required) February/March 2024 Anticipated Award Date February/March 2024 Anticipated Period of Performance

2.5 STANDARD PROPOSAL REQUIREMENTS

A. Proposals that address only part of the requirements contained in this RFP will be considered non-responsive.

B. SWK Programs reserves the right to:

a. reject any and all proposals.

b. negotiate portions thereof including the submitted cost proposals/budget.

c. select the proposal based on the best value to the company. The Respondent shall furnish additional information that the evaluation team may require in order to complete the evaluation of the proposals submitted. Failure to provide the requested material or information will disqualify the proposal.

d. cancel or re-issue the RFP at any time.

e. request and record and/or videotape all Webinars, Web demos, conference calls, demos or other communications relative to this RFP.

C. The Respondent must work with SWK staff to clarify the design of the materials, project design, project activities, and/or other products, and modify these items if necessary.

D. Proposals must be valid until the RFP has closed or been awarded.

E. Proposals may be withdrawn at any time prior to the submission time specified in this RFP, provided notification is received in writing. Proposals cannot be changed or withdrawn after the time designated for receipt.

2.6 NON-DISCLOSURE AGREEMENTS

Respondent shall sign a non-disclosure agreement upon award and execution of a subcontract. All information and data furnished to the Respondent during the solicitation process shall be treated as confidential to SWK. Any oral or written disclosure to unauthorized individuals is prohibited and can be grounds for proposal dismissal and termination of any subcontract awarded.

2.7 PROPOSAL PREPARATION COSTS

All costs associated with the preparation, submission, and any other-related activities before award of a subcontract resulting from there are the sole responsibility of the Respondent.

2.8 DISCLOSURE OF PROPOSAL CONTENT

Respondent may protect trade secret and confidential information from public release. If the Respondent asserts that information provided in the proposal is trade secrets or other confidential information, it must be clearly marked. Such information must be in boldface type and include the words “confidential” or “trade secret” at top of the page.

2.9 VENDORS CONFERENCE

Respondent must protect trade secret and confidential information from public release. If the Respondent asserts that information provided in the proposal is trade secrets or other confidential information, it must be clearly marked. Such information must be in boldface type and include the words “confidential” or “trade secret” at top of the page.

SWK, at its sole discretion, may elect to host a vendor conference in relation to this RFP. A vendor conference is designed to complete the following objectives:

Review the formal solicitation and specific requirements with vendors

Allow vendors to ask clarifying questions on the formal solicitation

Respondents are encouraged to notify the Sole Point of Contact and Communications listed below, regarding participation in the conference. People with disabilities who wish to attend the meeting and require auxiliary aids or services should contact the Sole Point of Contact listed below at least seventy-two (72) hours before the meeting in order to have reasonable accommodations made by SWK.

SWK may host a vendor conference for this RFP.

Sole Point of Contact and Communications: financeprocurementsolicitations@swkey.org.

2.10 CONFLICT OF INTERESTS

A Respondent will not be selected if it has a conflict of interest that will or may arise during the performance of its obligations under the subcontract. For this reason, Respondent’s response to this RFP must disclose any existing or potential conflicts of interest or possible issues that might create appearances of impropriety relative to the submission of a proposal from Respondent and its proposed subcontractors, possible selection as successful Respondent, or its performance of the subcontract.

For purposes of this RFP, “personal relationship” is defined as a current or past connection other than a clearly contractual, business, financial, or similar relationship and includes family relationships or other connections outside simply providing a response to this RFP. These connections must be disclosed if a reasonable person could expect the connection to diminish Respondent’s independence of judgment or effectiveness in the performance of Respondent’s responsibilities to SWK Programs under the subcontract.

Connections also fall within this definition if a reasonable person could expect the connection, within the overall context of Respondent’s submission of a proposal, possible selection as successful Respondent, or its performance of the subcontract, to create an issue for the company’s consideration relative to a potential appearance of impropriety or conflict of interest.

By submitting a response, Respondent agrees that it is under a continuing duty to supplement its response under this provision and that the duty to disclosure of any conflicts of interest is an ongoing obligation throughout the term of the subcontract. If the circumstances certified by the Respondent change or additional information is obtained after submission of proposals, Respondent shall submit updated information as soon as reasonably possible upon learning of any change to their affirmation. Report conflicts of interest to:

SWK VP of Compliance and Ethics dberndt@swkey.org

508-725-6151

3 PROPOSAL FORMAT AND CONTENT

3.1 PROPOSAL FORMAT AND CONTENT

Proposals must be submitted in electronic format (i.e., Word, PDF) and include the sections referenced in this Section 3. A transmittal letter must accompany the proposal and include the following details:

a) Respondent’s commitment to performing the implementation of the work within the project schedule.

b) Brief executive summary of the proposal contents.

c) A statement that the signatory of the transmittal letter has the authority to bind the Respondent.

Include name, title, and contact information.

3.1.1 Proposal Cover Page

Proposals should include a cover page which clearly states the name of the firm or organization, business address, and the name, position, and telephone number of the Respondent’s Proposal Administrator who may be contacted regarding the proposal. See Attachment C.

3.1.2 Table of Contents

Present a clear and comprehensive identification of your proposal's contents by section and page number.

3.1.3 Response Checklist

This checklist is to assist Respondent in ensuring that all information is included in their response.

Respondent must refer to the appropriate section of the RFP for detailed information on the following:

Optional Notice of Intent to Submit a Proposal Attachment B Transmittal Letter Section 3.1 RFP Cover Page Section 3.1.1 / Attachment C Table of Contents Section 3.1.2 Requirements Plan Section 3.2 Timelines Section 3.3 Cost Proposal Section 3.4 Respondent’s Profile and Financial Responsibility Section 3.5 / Attachment D & E Current Certificate of Insurance and Completed W-9 Attachment D Additional Terms and Conditions Attachment H Evidence of Historical Underutilized Business, if applicable Section 4.2

3.2 REQUIREMENTS PLAN

The Respondent must describe how their organization will meet the scope of work detailed in Section 1.3.3 and provide enough information to adequately evaluate the proposal as detailed in Section 4.2 Selection

Criteria. It is recommended that the requirements plan maintain the same outline or order as the scope of work when providing detail on the project details.

3.3 TIMELINES

Respondent must plan for a project starting date of no earlier than early-to-mid 2024 and an ending date of early-to-mid 2025 if selected as the contractor. The Respondent must submit a task/activity plan specifying, to the degree possible, the tasks and activities which are to be undertaken. Timelines showing beginning and ending dates for each major task are to be included, as well as the name(s) of person(s) responsible for each task. Activities must be sufficiently designed and outlined in the task/activity plan to provide evidence of satisfactory delivery of services and products. Time frames must be logical and appropriate to complete all activities within the beginning and ending dates of the subcontract. Failure to meet this condition shall result in disqualification of the proposal, and the proposal shall receive no further consideration.

3.4 COST PROPOSAL

The Respondent must submit a cost proposal detailing costs necessary to accomplish the project objectives and activities outlined in a task/activity plan. The cost proposal detail must be submitted in Excel or Excel-compatible format. Respondent should carefully consider the costs provided as changes may not be allowed during negotiations.

3.5 RESPONDENT’S PROFILE AND FINANCIAL RESPONSIBILITY

Respondent must submit a company profile detailing the following:

a) Basic organizational information, such as the size of the organization, how long the organization has been in business, whether the organization is a public or private entity, etc.

b) Location of the organization’s offices.

c) The range of services provided.

d) List of similar customers.

Respondent must submit a summary of its qualifications (not to exceed 3 pages). The summary should include details about the Respondent’s expertise in the area of third-party administration.

Respondent must submit at least three (3) references where the Respondent provided similar services (Attachment E).

Respondent may be required to submit indicators of financial stability before award. Examples of requested documentation include:

Most recent audited financial statements or certified public accountant compiled financial report.

Articles of organization and/or documents of incorporation.

3.6 ADDITIONAL TERMS AND CONDITIONS

Respondents must provide any additional terms and conditions that it would like considered in addition to SWK's General Terms and Conditions. Additional terms and conditions not provided with Respondent's proposal submission will not be considered if Respondent should be awarded a contract under this RFP.

4 REVIEW OF PROPOSALS

4.1 REVIEW OF PROPOSALS

Review of proposals will begin as soon as practical after receipt. The evaluation team shall consist of SWK staff knowledgeable in the content area. The recommendations of the evaluation team will be assembled and presented to senior executive staff who will:

1. Approve the proposal in whole or in part;

2. Disapprove the proposal; or

3. Defer action on the proposal for such reasons as a requirement for further evaluation.

SWK may not disclose any information until a subcontract is executed by both parties. Additional copies of proposals not selected for funding will be destroyed in accordance with an approved Records Retention Policy.

4.2 SELECTION CRITERIA

Proposals will be selected based on the ability of each Respondent to carry out all the requirements contained in this RFP. A Respondent who is in default or otherwise not in good standing under any other current or prior subcontract with SWK at the time of selection will not be eligible for award of this subcontract. SWK will base its selection on, among other considerations, demonstrated competence, qualifications of the Respondent, past performance, and proposed budget/cost. The following are the criteria and the total number of points for each portion of the RFP that will be applied in selecting a subcontractor.

SELECTION CRITERIA FOR SERVICES POSSIBLE

POINTS

A. Cost Proposal:

The proposal shall provide a price breakdown through the attached pricing schedule and all other costs required to provide the necessary support. SWK seeks the best level of effort the company feels is suitable to accomplish the work contained in the proposal.

Source: Section 3.2.1 Cost Proposal

Source: Attachment H (Workers Compensation Pricing Schedule)

B. Technical Approach:

Describes how the Respondent will meet and comply with the quality standards established in the proposal. At a minimum, the Quality Control Plan (QCP) must include a self-inspection plan, an internal staffing plan, and an outline of the Respondent's procedures to maintain quality, timeliness, responsiveness, customer satisfaction, and any other requirements outlined in this RFP.

Source: Section 1.3.3 (Scope of Work)

C. Personnel Qualifications:

The Respondent staff resumes reflect academic qualifications and the length and variety of experience in similar and relevant tasks related to Workers Compensation.

Source: Section 1.3.3 (Scope of Work) / Attachment C (Respondents Company Profile

E. Past Performance & Experience

The Respondent provided a list of three but no more than five references of relevant past and present contracts for Federal, State, and City agencies and commercial within the past three years, and a minimum of two references provided a positive reference for the scope of services.

The Respondents address knowledge and experience related to organizational change management, Internal Communications Development and Execution, and Staff Training and Development for large Non-Profit or Governmental agencies.

Source: Attachment C / D (Respondents Profile and Financial Responsibility, References)

E. Terms and Conditions

1. The vendor demonstrated and acknowledged a comprehensive understanding and alignment with SWK Terms and Conditions, including all required legal and ethical standards (5 points).

The Respondent was clear and transparent in their proposal in explaining how they will adhere to SWK Terms and Conditions and/or proposed additional terms and conditions (5 points).

E. Historical Underutilized Business:

1. Respondents who are classified as an underutilized business or use an underutilized business as a subcontractor and provide evidence of the certification (5 points).

Source: Section 4.4 Encouraged Participants

Total 100

4.3 DISCRIMINATION

No person shall, on the grounds of race, color, national origin, sex, age, disability, religion, citizenship status, genetic information, sexual orientation, gender identity, or any other protected class, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any SWK program or activity.

4.4 ENCOURAGED PARTICIPANTS

It is the policy of SWK that the following business enterprises have the maximum opportunity to participate in the purchasing and contracting process: (1) Small Businesses, (2) Women-Owned Businesses, (3) Minority-Owned Businesses, (4) Labor Surplus Area firms and (5) Veteran-Owned Businesses.

Accordingly, SWK encourages all the aforementioned business enterprises to compete for, win, and receive contracts for goods, services, and construction. Also, SWK encourages all companies to sub-contract portions of any SWK subcontract to the aforementioned business enterprises.

4.5 BEST AND FINAL OFFER

When deemed appropriate, after the submission of proposals but before the final selection of the successful proposal, SWK may request a best and final offer (“BAFO”) from Respondent(s). SWK will provide each Respondent within the competitive range with an equal opportunity for discussion and revision of their proposal. A Respondent may elect not to amend their original proposal. SWK is not bound to accept the best-priced proposal if that proposal is not the most advantageous to SWK as determined by the evaluation team.

5 CONTRACTUAL REQUIREMENTS

5.1 RESPONDENT’S PROPOSAL

Portions of the selected proposal(s) may be incorporated into the subcontract prepared by SWK for signature by the contracting parties.

5.2 MATERIAL & PRODUCT REQUIREMENTS

SWK reserves the right to review any materials, and/or products developed or adapted by the Subcontractor. Upon completion of the subcontract period, all documents will be returned to SWK or destroyed accordingly. All documents created at any time during the subcontract period belong to SWK. A designated SWK staff (i.e., project manager) will establish procedures for communicating phase out and transition of the deliverable(s).

5.3 VENDOR PERFORMANCE

SWK reserves the right to monitor vendor performance including, but not limited to, billing reviews, desk reviews, monitoring visits, vendor questionnaires, and requesting documents or information to validate performance.

5.4 PAYMENT

SWK’s payment terms are Net 30. Payment is only by reimbursement upon satisfactory performance of services or receipt of items. Payment is contingent upon submission of properly prepared and certified invoices. The information provided on each detailed status report must coincide with the tasks outlined in the approved budget, as negotiated by SWK.

5.5 VENDOR REGISTRATION IN ORACLE

Oracle serves as the primary procurement system for SWK, including vendor management. The Successful Respondent will be required to register in Oracle. Additionally, if the Respondent is to deliver goods to SWK, the Respondent must provide SWK with a list of contracted items for integration into the item data master within Oracle upon award.

Registration instructions are available at Supplier Registration Instructions on our YouTube channel.

Vendors can register using the Supplier Portal link Supplier Registration. Once logged into Oracle, vendors can add the required vendor information, upload the requested documents, and complete the vendor questionnaire located in the Supplier Portal.

6 APPENDIX

ATTACHMENT A – TERMS AND CONDITIONS AND RELATED FORMS AND LINKS

ATTACHMENT B – NOTICE OF INTENT TO SUBMIT A PROPOSAL

ATTACHMENT C – COVER PAGE SUGGESTED FORMAT FOR PROPOSAL

ATTACHMENT D – RESPONDENT COMPANY PROFILE FORM

ATTACHMENT E – RESPONDENT REFERENCES FORM

ATTACHMENT F – TPA QUESTIONNAIRE

ATTACHMENT G – ADDITIONAL PROVISIONS

ATTACHMENT H – PROGRAM LOCATIONS

ATTACHMENT I – SWK LOCATIONS

ATTACHMENT J – SPECIAL CLAIMS HANDLING INSTRUCTIONS

ATTACHMENT K - COST PROPOSAL

1 5/17/2023

ATTACHMENT A

All Respondents must reference Southwest Key Program's vendor page for all applicable Terms and Conditions: https://southwestkey.org/procurement/

Respondents encouraged to provide redlines to SWK's Terms and Conditions as part of their proposal submission, if any.

5/17/2023

VENDOR NONDISCLOSURE AGREEMENT

This VENDOR NONDISCLOSURE AGREEMENT (this “Agreement”) is made and entered by and between Southwest Key Programs, Inc. (“SWK”), and the entity or person identified on the signature block below (“Contractor”), and governs the disclosure of Confidential Information (as defined below) between the parties.

Discloser shall mean the party disclosing the Confidential Information. Recipient shall mean the party receiving the Confidential Information.

Recipient understands that Discloser has disclosed or may disclose, either directly or indirectly in writing, orally, or by inspection of tangible objects, to Recipient information relating to Discloser’s business that is confidential or proprietary in nature, whether explicitly designated as such or which in good faith ought to be treated as such given its nature and/or the nature of the disclosure (which to the extent previously, presently or subsequently obtained by Recipient is hereinafter referred to as “Confidential Information”).

Confidential Information may include, but shall not be deemed to be not limited to, the following:

i. non-published patent applications and the information contained therein, trade secrets, inventions (whether patentable or not), discoveries and improvements;

ii. (ii) concepts, know-how, ideas, inventions, products, techniques, processes, methodologies, testing procedures, design and functional specifications, analysis and performance information, sketches, drawings, models, apparatus, equipment, user documentation, internal documentation, engineering information, hardware configuration information, technical or other representations, documentation, diagrams, schematics, flow charts, features, mode of operation and other details of products and services, and information concerning research, experimental work, development, design documents, details and specifications;

iii. (iii) software design and architecture, software programs, source code, object code and other computer code, modules, software source documents, specifications, algorithms, formulas, scripts, data, databases, and formulas related to the current, future and proposed products and services;

iv. (iv) names and expertise of directors, officers, employees and consultants;

v. (v) procurement requirements, purchasing, customer data, customer lists, customer names, suppliers and strategic partners, and lists thereof; and

vi. (vi) technical, business, financial, marketing, customer, supplier and product development plans, schedules, forecasts, strategies, analysis, budgets, materials sales, merchandising, promotional and marketing plans and information.

Without limiting the foregoing, Confidential Information also may include proprietary or confidential information of any third party who may disclose such information to Discloser in the course of Discloser’s business, and for purposes of this Agreement, as between the parties such third-party confidential information shall be deemed Discloser’s Confidential Information.

In consideration of any access Recipient may have to Confidential Information and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows:

1. Recipient agrees:

ATTACHMENT A

i. to hold any Confidential Information in strict confidence and to take all reasonable precautions to protect such Confidential Information;

ii. not to divulge any Confidential Information or any information derived therefrom to any third party, including, but not limited to, any affiliated entity (even if owned or controlled by Recipient);

iii. not to make any use whatsoever at any time of any Confidential Information except solely as needed to evaluate whether to enter into a business relationship with Discloser or as otherwise specifically agreed in writing (the “Purpose,” which in no case shall be deemed to extend to allow any use by Recipient that might reasonably cause current or future commercial damage to Discloser);

iv. not to copy or create derivative works of any Confidential Information without prior written approval by Discloser;

v. not to alter or delete any proprietary legends or markings on any Confidential Information; and

vi. not to decompile, disassemble, reverse engineer or otherwise attempt to derive the composition or underlying information, structure or ideas of any Confidential Information.

2. Discloser agrees that the foregoing clauses (i), (ii), (iii), (iv), (v) and (vi) shall not apply or shall cease to apply (as applicable) with respect to any information Recipient can show as a matter of contemporaneous record and otherwise by clear and convincing evidence:

i. (a) was already in Recipient’s possession prior to disclosure by Discloser;

ii. (b) was developed by Recipient without reference to any Confidential Information;

iii. (c) was obtained from a third party who is not prohibited from transmitting the information to Recipient by a contractual, legal or fiduciary obligation to Discloser; or

iv. (d) is or becomes generally available to the public other than as a result of any action or inaction by Recipient;

Provided, however, that should any information come within any circumstance listed in the foregoing clauses (i), (ii), (iii), and (iv) it does not authorize Recipient to infringe any proprietary rights of Discloser.

Recipient may make disclosures of Confidential Information required by court order, provided Recipient promptly notifies Discloser of the disclosure requirement and cooperates with Discloser’s reasonable efforts to resist or narrow the disclosure and to obtain an order or other reliable assurance that confidential treatment will be afforded the Confidential Information.

3. Recipient agrees that it shall take all reasonable measures to protect the secrecy of and avoid disclosure and unauthorized use of the Confidential Information. Without limiting the foregoing, Recipient shall take at least those measures that Recipient takes to protect its own most highly confidential information and shall have its employees, if any, who have access to Confidential Information sign a non-use and non-disclosure agreement in content substantially similar to the provisions hereof, prior to any disclosure of Confidential Information to such employees.

4. Recipient shall reproduce Discloser’s proprietary rights notices on any such approved copies, in the same manner in which such notices were set forth in or on the original.

5. Recipient shall immediately notify Discloser in the event of any unauthorized use or disclosure of the Confidential Information.

6. No terms in this section shall prohibit or restrict Recipient’s ability to report, in accordance with applicable law, any fraud, waste, or abuse of government funds to an investigative or law enforcement representative of a federal department or agency authorized to receive such information.

7. Recipient is prohibited from requiring its employees or contractors to agree to confidentiality agreements or statements that prohibit or restrict the reporting of fraud, waste, or abuse.

8. Recipient agrees not to remove or export from the United States or re-export any Confidential Information or any direct product thereof except in compliance with, and with all licenses and approvals required under, applicable export laws and regulations, including without limitation, those of the United States Department of Commerce.

9. Immediately upon (i) the decision by either party not to enter into a business relationship or (ii) the request of Discloser, Recipient will turn over to Discloser all Confidential Information and all documents or media containing any Confidential Information and any and all copies or extracts thereof. Upon Discloser’s request, Recipient will provide Discloser with a certificate attesting that all Confidential Information has been returned to Discloser. Recipient shall not be required to return or destroy any Confidential Information housed in automated backup system or if required under law to maintain records. Such Confidential Information shall continue to be controlled under this Agreement.

10. Recipient understands and agrees that nothing herein requires Discloser (i) to disclose any Confidential Information, which shall be disclosed, if at all, solely at the option of Discloser, or (ii) to proceed with a business relationship or any relationship in connection with which Confidential Information may be disclosed.

11. ALL CONFIDENTIAL INFORMATION IS PROVIDED “AS IS.” DISCLOSER MAKES NO WARRANTY, EXPRESS OR

IMPLIED, REGARDING THE TIMELINESS, ACCURACY OR COMPLETENESS OF ANY CONFIDENTIAL

INFORMATION.

12. This Agreement does not grant any rights to Recipient under any patent, copyright or other intellectual property right of Discloser, nor shall this Agreement grant Recipient any rights in or to Confidential Information except as expressly set forth herein. As between Recipient and Discloser, all Confidential Information and any derivatives thereof, whether created by Discloser or Recipient, shall remain the sole property of Discloser.

13. Recipient’s obligations under this Agreement will continue until such time as and only to the extent that Confidential Information is publicly known and made generally available through no action or inaction of Recipient.

14. Recipient acknowledges and agrees that due to the unique nature of the Confidential Information, there may be no adequate remedy at law for any breach of Recipient’s obligations hereunder and that any such breach may allow Recipient and/or third parties to unfairly compete with Discloser resulting in irreparable harm to Discloser. Recipient agrees that upon any such breach or any threat thereof, Discloser shall be entitled to seek appropriate equitable and/or injunctive relief in addition to whatever remedies it might have at law (without being required to post a bond or other security) and to be indemnified by Recipient from any loss or harm, including, without limitation, reasonable attorneys’ fees, in connection with any breach or enforcement of Recipient’s obligations hereunder or the unauthorized use or release of any Confidential Information. Recipient shall notify Discloser in writing immediately upon the occurrence of any such unauthorized release or other breach of which it is aware and shall cooperate with Discloser in every reasonable way to help Discloser regain possession of such Confidential Information and prevent its further unauthorized use or disclosure.

15. In the event any provision of this Agreement shall be held by a court of competent jurisdiction to be illegal, invalid or unenforceable, the remainder of this Agreement shall remain in full force and effect and the illegal, invalid or unenforceable provision shall be modified so as to be fully enforceable and to achieve to the maximum extent possible the business and economic purposes of the provision as originally drafted.

16. This Agreement shall be governed by the laws of the State of Texas without regard to the conflicts of law provisions thereof, and the parties consent to the exclusive jurisdiction and venue of the state and federal courts located in Travis County, Texas and agree to waive all objections to personal jurisdiction, venue and forum non conveniens.

17. This Agreement supersedes all prior discussions and writings and constitutes the entire agreement between the parties with respect to the Confidential Information disclosed pursuant to this Agreement.

18. This Agreement shall bind the respective officers, agents, employees and representatives of the parties and shall inure to the benefit of the parties, their successors and permitted assigns.

19. No waiver, modification or amendment of this Agreement will be binding upon either party unless made in writing and signed by a duly authorized representative of such party, and no failure or delay in enforcing any right will be deemed a waiver thereof.

20. Notices hereunder will be effective only if in writing and upon receipt if delivered personally or by overnight mail carrier or facsimile transmission confirmed by mailing, or three (3) days after deposit in the United States mail, first class postage prepaid.

21. Any ambiguous language in this Agreement shall be interpreted as to its fair meaning, and not strictly for or against either party, regardless of whether either party drafted the Agreement.

22. The prevailing party in any action to enforce this Agreement shall be entitled to costs and fees (including reasonable attorneys’ fees and expert witness fees) incurred in connection with such action.

SOUTHWEST KEY PROGRAMS, INC.

By: ___________________________________

CONTRACTOR

By: ___________________________________

Name: _________________________________ Name: _________________________________ Title: __________________________________ Title: __________________________________ Date: ____________________

Date: ____________________

ATTACHMENT B

OPTIONAL NOTICE OF INTENT TO

SUBMIT A PROPOSAL

RFP #

Project Title:

The undersigned organization hereby files a notice of intent to submit a proposal:

Name of Organization:

Mailing Address:

Contact Person:

E-Mail:

Phone Number:

FAX:

• Filing of this notice is not mandatory; however, it will assist Southwest Key Programs in anticipating the volume of proposals in order to better expedite the review process and finalize contract awards.

• Filing this notice in no way binds the organization to submit a proposal for this RFP.

• Respondents who do not file this notice are still eligible to submit a proposal.

PLEASE SUBMIT THIS NOTICE TO BONFIRE AS SOON AS POSSIBLE AFTER

RECEIPT OF THE RFP, BUT NOT LATER THAN THE DATE SPECIFIED IN

BONFIRE.

ATTACHMENT C

(FORMAT FOR COVER PAGE)

PROPOSAL

Submitted to

Southwest Key Programs Procurement Department

RFP #:

TITLE OF PROPOSAL: Provide name of proposal as indicated on the RFP.

RESPONDENTORGANIZATION: Name and address of organization submitting proposal (include zip code)

RESPONDENT ORGANIZATION

IDENTIFICATION NUMBER:

Show Respondent organization Federal Employer's Identification Number

PROPOSAL DEVELOPED BY: Name, position, email, and telephone number of the person responsible for development of proposal

PROJECT ADMINISTRATOR: Name, position, email, and telephone number of the person to oversee the proposed project

PROPOSAL TRANSMITTED BY:

Name, position, email, and telephone number of the official committing the Respondent organization to the proposed project

CONTRACTING OFFICER:

Name, position, email, and telephone number of official with authority to negotiate contracts for Respondent organization

DURATION OF PROJECT: Beginning and ending dates of proposed project

TOTAL BUDGET FOR PROPOSAL

PROJECT: Total of projected expenditures listed in budget section

CONTAINS PROPRIETARY INFORMATION: Indicate yes/no if proposal being submitted contains proprietary information

DATE SUBMITTED: Date proposal is submitted to SWK

ATTACHMENT D – RESPONDENT COMPANY PROFILE FORM

Respondents are required to complete all information in order to be considered responsive. If any part of this information is missing, Respondents will be screened out upon proposal submission and will not be considered for award.

Company Profile Form

Company/Entity Name:

Business name/disregarded entity name, if different from above (DBAs) from the last five (5) years:

Address:

Telephone:

Employer Identification Number:

Unique Entity Identifier:

Number of Employees:

Office Locations & Number of Offices:

Years in Business:

Business Licenses (relevant licenses, permits, and certifications):

Provide information about your production facilities and capacity (if proposing goods)

Contact Name:

Title:

Company Contact Form

Accounts Payable Contact Form

Accounts Payable Contact Name:

Accounts Payable Contact Title:

Accounts Payable Contact

Accounts Payable Contact Email:

Please submit the following documents with the response or bid:

A W-9, Request for Taxpayer Identification Number and Certification A current Certificate of Insurance (COI) Most recent audited financial statements or certified public accountant compiled financial reports for the last three (3) years; and Annual revenue for the past three (3) years.

Email:

ATTACHMENT E

(FORMAT FOR REFERENCE FORM)

REFERENCE FORM

Company or Entity Name:

Address:

Contact Name:

Telephone / Email:

Business Reference

Company or Entity:

Contact Name:

Contact Telephone or Email:

Brief Description of Work:

Amount of Contract:

Contract Start / End Date:

Business Reference

Company or Entity:

Contact Name:

Contact Telephone or Email:

Brief Description of Work:

Amount of Contract:

Contract Start / End Date:

Business Reference

Company or Entity:

Contact Name:

Contact Telephone or Email:

Brief Description of Work:

Amount of Contract:

Contract Start / End Date:

Third Party Administrator – Questionnaire

1. Describe the services your firm provides with specific emphasis on third-party administration of Workers' Compensation claims. Please describe additional services available beyond claims administration, such as loss control/safety, training, claims information systems, etc., including any associated costs.

2. Explain how you will handle claims when the primary adjuster is out.

3. Describe the claims management information system used by your firm and any access available to

SWK. Describe reporting and ad-hoc report capabilities and training provided to SWK staff to support this capability. Identify any cost associated with client access that is not included in the fee proposed for claims adjusting and administration.

4. How do you protect your client's data for security and privacy?

5. Provide a summary describing how you perform the following:

a. Review of usual, customary, and reasonable medical charges

b. Duplicate billings and duplicate payments

c. Duplicate claims filed

d. Selection of physician for independent medical exam

e. Peer review or other means of reporting suspected medical malpractice

f. Overpayment of benefits

6. Provide a summary of your quality control program and internal control procedures.

7. Describe your documentation procedure for handling customer complaints.

8. Describe your internal audit procedures for the claim office. Include the frequency of audits, who performs them, and what percentage of claims are audited.

9. How frequently do claim supervisors review open claims? Is a diary system used for this?

10. How are reserves established and monitored?

11. How are allocated expenses monitored and adjusted?

12. Disclose any set-up or transition fees, if any. This includes system set-up, data conversion, training, and any other one-time fees.

13. Is your firm an approved vendor with Safety National?

14. Is your firm capable of bridging with Origami?

15. Is over 50% of your staff Bilingual?

ATTACHMENT F

REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION FOR COVERED

CONTRACTS

Name of Business (Contractor)

Vendor ID No. or Social Security No.

(1) The prospective contractor certifies to the best of its knowledge and belief that it and its principals:

(a) Are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this application 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;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

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

(2) Where the prospective contractor is unable to certify to any of the statements in this certification, such prospective contractor shall attach an explanation to this proposal.

Signature of Contractor Representative Date

Printed/Typed Name of Printed/Typed Title of Contractor Representative Contractor Representative

Attachment G

CERTIFICATION

Certification for Formal Solicitation Number

The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to…