Form_1._Personal_Professional_Sub-consultant_Disclosure_Form.pdf
PDF 1 MB Posted
- Attached to
- Insurance Agent of Record
- Solicitation number
- 26-076
- Issued by
- Washington County, Barlow City, Oregon
About this file
This is a Subconsultant Disclosure Form used by the City of Beaverton, Oregon in conjunction with a personal/professional services contract opportunity for an Insurance Agent of Record. The form is designed to capture comprehensive information about all subconsultants—both certified and non-certified—that a primary contractor intends to utilize for the project. The City of Beaverton is seeking sealed proposals from qualified insurance agents to provide professional services in the administration of its Risk Management Program for a term of up to six years. The scope of services includes procurement of casualty insurance, property insurance, and excess workers' compensation insurance on behalf of the city, excluding health or dental insurance coverage.
The Subconsultant Disclosure Form requires bidders to list up to eight subconsultants with detailed information including complete legal names, addresses, phone numbers, description of scope of work to be performed, dollar value of each subcontract, and all applicable business certifications such as Emerging Small Business (ESB), Minority-Owned Business (MBE), Women-Owned Business (WBE), Service-Disabled Veteran-Owned Business (SDV), and Disadvantaged Business Enterprise (DBE/ACDBE) designations. The form appears in multiple versions within the document, suggesting it may have been revised or provided in multiple formats. Bidders are required to disclose all subconsultant arrangements to ensure transparency in the contracting process and to facilitate the City's verification of compliance with applicable small business and diversity requirements.
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Text version
Company Name: ______________________________________ Project Name: _____________________________________________________
LIST ALL SUBCONSULTANTS —CERTIFIED AND NON-CERTIFIED
ALL SUBCONSULTANTS
(Use the Subconsultants complete legal name)
DESCRIPTION OR SCOPE OF WORK
(TYPE OF WORK TO BE PERFORMED)
DOLLAR VALUE OF
SUBCONTRACT
LIST ALL CERTIFICATIONS
(ESB; MBE, WBE, SDV, DBE, ACDBE)
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
*ESB: Emerging Small Business; MBE: Minority-owned Business; WBE: Women-Owned Business; SDV: Service-Disabled Veteran-Owned Business;
DBE & ACDBE Disadvantaged Business Enterprise Rev 5/6/19
CITY OF BEAVERTON
PERSONAL / PROFESSIONAL SERVICES CONTRACT: SUBCONSULTANT DISCLOSURE FORM 1
ALL SUBCONSULTANTS
(Use the Subconsultants complete legal name)
DESCRIPTION OR SCOPE OF WORK
(TYPE OF WORK TO BE PERFORMED)
DOLLAR VALUE OF
SUBCONTRACT
LIST ALL CERTIFICATIONS
(ESB; MBE, WBE, SDV, DBE, ACDBE)
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
Name ______________________________________
Address ____________________________________
City/St/Zip __________________________________
Phone ______________________________________
*ESB: Emerging Small Business; MBE: Minority-owned Business; WBE: Women-Owned Business; SDV: Service-Disabled Veteran-Owned Business;
DBE & ACDBE Disadvantaged Business Enterprise Rev 5/6/19
CITY OF BEAVERTON
PERSONAL / PROFESSIONAL SERVICES CONTRACT: SUBCONSULTANT DISCLOSURE FORM 1
LIST ALL SUBCONSULTANT—CERTIFIED AND NON-CERTIFIED
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File details come from the government source that posted it. Updated .