Fillable_OMESFormCP076.pdf
PDF 224 KB Posted
- Attached to
- OEIBA Program Commercial HMO, MSP, and MAPD Plans State and local contract opportunity
- Solicitation number
- EV00000681
- Issued by
- Oklahoma County, Hobart City, Oklahoma
About this file
This document is an Oklahoma Office of Management & Enterprise Services (OMES) "Responding Bidder Information" form (OMES FORM CP 076), a standard state procurement document that bidders must complete when responding to a solicitation. The form requires bidders to provide comprehensive company information, including contact details, potential conflicts (such as Israeli goods boycotts), state registration status, workers' compensation insurance coverage, and veteran business enterprise status.
The form includes several key compliance sections that bidders must address, such as confirming registration with the Oklahoma Secretary of State for contracts over $25,000, providing workers' compensation insurance documentation, and declaring whether they qualify as a service-disabled veteran business. Bidders must also affirm they are not engaged in a boycott of goods or services from Israel, and provide appropriate certifications or exemption statements for various statutory requirements. The form is designed to ensure vendor transparency, legal compliance, and verification of business credentials before potential contract award.
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Text version
OMES FORM CP 076 Rev. 11/2020 PAGE 1 OF 2
Responding Bidder Information
“Certification for Competitive Bid and Contract” MUST be submitted along with the response to the Solicitation.
1. RE: Solicitation #: ______________________________________
2. Bidder General Information:
FEI / SSN : Supplier ID:
Company Name:
3. Bidder Contact Information:
Address:
City: State: Zip Code:
Contact Name:
Contact Title:
Phone #: Fax #:
Email: Website:
4. Bidder currently engaged in a boycott of goods or services from Israel.
YES
NO
5. Registration with the Oklahoma Secretary of State: (if over $25,000)
YES - Filing Number:
NO - Prior to the contract award, the successful bidder will be required to register with the Secretary of State or must attach a signed statement that provides specific details supporting the exemption the supplier is claiming (www.sos.ok.gov or 405-521-3911).
6. Workers’ Compensation Insurance Coverage:
Bidder is required to provide with the bid a certificate of insurance showing proof of compliance with the Oklahoma Workers’ Compensation Act.
YES – Include with the bid a certificate of insurance.
NO – Exempt from the Workers’ Compensation Act pursuant to 85A O.S. § 2(18)(b)(1-11) – Attach a written, signed, and dated statement on letterhead stating the reason for the exempt status.1
1 For frequently asked questions concerning workers’ compensation insurance, see https://www.ok.gov/wcc/Insurance/index.html http://www.sos.ok.gov/ https://www.ok.gov/wcc/Insurance/index.html
OMES FORM CP 076 Rev. 11/2020 PAGE 2 OF 2
7. Disabled Veteran Business Enterprise Act
YES – I am a service-disabled veteran business as defined in 74 O.S. §85.44E. Include with the bid response 1) certification of service-disabled veteran status as verified by the appropriate federal agency, and 2) verification of not less than 51% ownership by one or more service-disabled veterans, and 3) verification of the control of the management and daily business operations by one or more service-disabled veterans.
NO – Do not meet the criteria as a service-disabled veteran business.
Authorized Signature Date
Printed Name Title
| Certification for Competitive Bid and Contract MUST be submitted along with the response to the Solicitation: |
| RE Solicitation: |
| FEI SSN: |
| Supplier ID: |
| Company Name: |
| Address: |
| City: |
| State: |
| Zip Code: |
| Contact Name: |
| Contact Title: |
| Phone: |
| Fax: |
| Email: |
| Website: |
| Bidder currently engaged in a boycott of goods or services from Israel: Off |
| Registration with the Oklahoma Secretary of State if over 25000: |
| YES Filing Number: Off |
| NO Prior to the contract award the successful bidder will be required to register with the Secretary of: Off |
| YES Include with the bid a certificate of insurance: Off |
| NO Exempt from the Workers Compensation Act pursuant to 85A OS 218b111 Attach a: Off |
| YES I am a servicedisabled veteran business as defined in 74 OS 8544E Include with the bid: Off |
| NO Do not meet the criteria as a servicedisabled veteran business: Off |
| Date: |
| Printed Name: |
| Title: |
| Signature2_es_:signer:signature: |
File details come from the government source that posted it. Updated .