HSS26021D-HCBS_appE.docx
DOCX document 22 KB Posted
- Attached to
- HCB Services for Individuals with Intellectual & Developmental Disabilities State and local contract opportunity
- Solicitation number
- HSS26021D-HCBS
- Issued by
- Delaware
About this file
This is a Supplemental Questionnaire (Appendix E) for the State of Delaware Division of Public Health's Home and Community Based (HCB) Services contract opportunity for individuals with intellectual and developmental disabilities. The questionnaire requires vendors to provide organizational information including legal entity name, address, primary and alternate contact details, and tax identification or Delaware Business License number. Vendors must also supply policy numbers for multiple types of insurance coverage, including Commercial General Liability, Automobile Liability, and Worker's Compensation & Employer's Liability insurance. Depending on the services provided, vendors must carry at least one additional insurance type from the following: Medical/Professional Liability, Miscellaneous Errors and Omissions, or Product Liability insurance.
Vendors applying for authorization to provide HCB services must submit certificates of insurance for each policy in effect, along with a declaration page listing covered vehicles for automobile liability coverage. The questionnaire includes an attestation section in which the vendor representative certifies that all provided information is true and complete and confirms that the applying organization is not excluded from participation in the Medicaid Program by the United States Office of Inspector General. Submission of this completed questionnaire is a mandatory requirement for vendors seeking to participate in this contract opportunity.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| HSS26021D-HCBS_rfp.pdf | ||
| HSS26021D-HCBS_appC.xlsx | XLSX spreadsheet | |
| HSS26021D-HCBS_appD.docx | DOCX document |
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Text version
APPENDIX E: Supplemental Questionnaire
Vendors are required to complete Part One of this questionnaire in its entirety.
PART ONE: ORGANIZATION INFORMATION
Name of Individual/Organization: Click here to enter name. Current Street Address: Click here to enter address.
City: Click here to enter city.
State: Click here to enter state. Zip Code: Click here to enter zip code.
Primary Contact First Name: Click here to enter name. Last Name: Click here to enter name. Primary Phone Number: Click here to enter number.
Primary E-mail Address: Click here to enter address.
Alternate Contact First Name: Click here to enter name. Last Name: Click here to enter name. Alternate Phone Number: Click here to enter number.
Alternate E-mail Address: Click here to enter address.
Tax ID Number: Click here to enter number.
(OR) Delaware Business License: Click here to enter number.
IRS 501(c)(3) Determination Letter (if applicable): Click here to enter number.
Commercial General Liability Insurance Policy Number: Click here to enter number. Automobile Liability Insurance Policy Number: Click here to enter number.
Worker’s Compensation & Employer’s Liability Insurance Policy #: Click here to enter number.
Umbrella/Excess Liability Insurance Policy Number: Click here to enter number.
Depending on services provided, Vendor must carry at least one of the following insurances: Medical/Professional Liability Insurance Policy Number: Click here to enter number.
Miscellaneous Errors and Omissions Insurance Policy Number: Click here to enter number. Product Liability Insurance Policy Number: Click here to enter number.
*Mandatory Requirement- Certificate(s) of Insurance for each policy in effect must accompany Supplemental Questionnaire. For Automobile Liability Insurance, declaration page listing covered vehicles is required.
STATE OF DELAWARE DIVISON OF PUBLIC HEALTH
PART TWO: ATTESTATION
I hereby certify the information provided in this supplemental questionnaire is true and complete. Further, signature below, indicates that Vendor applying for authorization to provide home and community based services for individuals with intellectual and developmental disabilities is not excluded from participation in the Medicaid Program by the United States Office of Inspector General (OIG), Division of Health and Human Services (DHHS).
| PRINT VENDOR REPRESENTATIVE NAME AND TITLE: |
| Click here to enter representative name. Click here to enter title. |
SIGNATURE:
File details come from the government source that posted it. Updated .