GIC Conflict of Interest Form.doc
DOC document 35 KB Posted
- Attached to
- NOI Providing Consulting Services to Assist in the Selection of a Life Insurance Carrier
- Solicitation number
- BD-15-1049-GIC00-07GIC-00000003561
- Issued by
- Suffolk County, Massachusetts
About this file
The document is a Certification - Conflict of Interest form issued by the Group Insurance Commission (GIC) of the Commonwealth of Massachusetts. The form requires bidders to certify that they have not performed any work or served in an advisory capacity related to the procurement of a life insurance carrier for the GIC, as outlined in RFR GICPND1503. Additionally, the form requires bidders to agree not to accept any payments from a potential carrier that relate to this or any other GIC engagement.
The related state and local contract opportunity is a notice inviting responses from employee benefits consultants and other interested parties to provide consulting services to the GIC. The GIC seeks a consultant to provide project management, actuarial analysis, and technical assistance in developing an RFR for a life insurance carrier to provide services to the GIC's life insurance plans.
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Text version
CERTIFICATION – CONFLICT OF INTEREST
CONSULTANTS
This is certify that the undersigned has carefully read the specifications contained in the Request for Responses (RFR) – GICPND1503 -- published by the Group Insurance Commission, and that the proposal transmitted herein is in accordance with all of the information and data contained in the RFR.
The undersigned bidder firm also certifies that it has not, either directly or through any subsidiary or affiliate organization, been hired to perform any work or has served in any paid or unpaid advisory capacity, related to the subject of RFR GICPND1503 for the benefit of any of the following organizations, their subsidiaries, or affiliates:
Firm Name:
Address:
Signature of Authorized Representative: _____________________________________________________
Date:
NOTE: If you believe that a conflict may exist, please provide a written statement to the GIC, prior to submitting a bid, with as much information as possible about the nature of the potential conflict. Please fax or email the information to Andrew Stern, GIC General Counsel, at (617) 227-5181 or Andrew.Stern@gic.state.ma.us. The GIC will attempt to provide a determination within one business day of receipt.
Commissions, Brokers Fees, Other Forms of Payment from Selected Carrier
This is to certify that the undersigned agrees not to accept any payments from a potential carrier or anyone associated with the carrier -- either directly or indirectly, including, but not limited to, commissions, brokers fees, carrier overrides, contingency payments, special producer payments, extra-contractual payments, services in-lieu-of payments, inclusion of GIC business in any bonus/volume calculations, etc. -- that relate in any way to this or any Group Insurance Commission engagement. In addition, the undersigned agrees to notify the GIC immediately if approached by a potential carrier or anyone associated with the carrier regarding payments to the consultant for information or work associated with securing business from the Group Insurance Commission.
Signature of Authorized Representative:____________________________________
Title:_____________________________________ Date:_____________________ Consultant Conflict of Interest RFR Revised 1.31.2014
File details come from the government source that posted it. Updated .