Human_Trafficking_Affidavit_11.20.25.pdf
PDF 115 KB Posted
- Solicitation number
- 26-0251-REQ
- Issued by
- Pinellas County, Florida
About this file
This is a Human Trafficking Affidavit form required by Pinellas County, Florida for the Request for Proposal 26-0251 Employee Benefits Concierge & Health Navigation Services. The affidavit requires an authorized contractor representative to attest under penalties of perjury that the contractor does not use coercion for labor or services as defined in Section 787.06 of the Florida Statutes. The form must be notarized and submitted as part of the proposal response. Proposals for employee benefits concierge and health navigation services for approximately 3,250 County benefits-eligible employees and their families must be submitted via the OpenGov procurement portal by March 5, 2026, at 3:00 p.m. The initial contract term is five years effective August 1, 2026, with two optional twelve-month renewal periods subject to mutual agreement. No site visits or bidders' conferences are scheduled. The question submission deadline is February 19, 2026, at 10:00 a.m.
Contractors must submit pricing in a specified Excel format using per-employee-per-month (PEPM) unit costs for two service lines: General Concierge Services and Health and Employee Benefits Navigation Services. Five vendors have been invited to submit proposals: Alight Health, Included Health, Quantum Health, Transcarent/Accolade, and Healthjoy. No set-asides for disadvantaged enterprises are indicated in the RFP documentation. Qualified contractors must demonstrate a minimum of three years of experience delivering health advocacy services to large public or corporate clients and must possess HITRUST and SOC2 certifications. Contractors must maintain Cyber Risk Liability insurance with $5,000,000 per occurrence limits and Professional Liability coverage of $1,000,000, register with the Florida Division of Corporations, comply with E-Verify requirements, and execute a HIPAA Business Associate Agreement. The RFP does not specify an explicit budget or award value; expenditures will be capped at an amount to be determined following award.
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Text version
HUMAN TRAFFICKING AFFIDAVIT
In accordance with section 787.06 (14), Florida Statutes, the undersigned, on behalf of ____________________________ (the “Contractor”), hereby attests that the Contractor does not use coercion for labor or services as defined in Section 787.06, Florida Statutes.
The undersigned must be an authorized representative of the Contractor who can execute this affidavit on the Contractor’s behalf.
Under penalties of perjury, I______________________, declare that I have read the foregoing affidavit and that the facts stated in it are true.
Signature: ______________________________ Print Name: ______________________________
Date: ______________________________ Federal Work Authorization User Identification No.: _____________________________ Name of Pinellas County Contract and Contract No.: ____________________________
STATE OF FLORIDA COUNTY OF ________________
The foregoing instrument was acknowledged before me by means of 1) physical presence __ or
2) online notarization___, this __________________________ (date) by ____________________________ of _____________________________________, a __________________________________ corporation, on behalf of the corporation.
He/she is personally known to me or has produced __________________________________ as identification.
[Notary Seal]
Notary Public: _________________________________________ Name typed, printed, or stamped: _________________________________________
My Commission Expires: _________________________________________
| Print Name: |
| Federal Work Authorization User Identification No: |
| Name of Pinellas County Contract and Contract No: |
| Notary Public: |
| Name typed printed or stamped: |
| My Commission Expires: |
| Contractor Name: |
| Contractor Name 1: |
| Pinellas County: |
| Date: |
| Check Box1: Yes |
| Notary Name: |
| 1: |
| 2: |
| Type of Identification: |
| Check Box2: Off |
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