OMESformCP076.pdf
PDF 286 KB Posted
- Attached to
- RFP HSA Administrator
- Solicitation number
- EV00000906
- Issued by
- Oklahoma County, Hobart City, Oklahoma
About this file
This file is the OMES Form CP076 Responding Bidder Information form used by the Oklahoma Office of Management and Enterprise Services (OMES) Central Purchasing division for the HSA Administrator solicitation issued on behalf of the Oklahoma Health Care Authority Employees Group Insurance Division. The form serves as the official bidder certification and information submission document that must accompany all responses to the solicitation. Bidders are required to complete sections providing solicitation number, general company information including FEIN/SSN and Supplier ID, contact details, and authorized signature with date and title. The solicitation pertains to the procurement of HSA administrative services to support members enrolled in the HealthChoice High Deductible Health Plan (HDHP) who elect to establish individual trust agreements.
The form includes eight certification and compliance sections that bidders must address, including attestation regarding boycott of Israeli goods or services, registration status with the Oklahoma Secretary of State, workers' compensation insurance coverage compliance with the Oklahoma Administrative Workers' Compensation Act, and eligibility status under the Disabled Veteran Business Enterprise Act. Responding bidders must include certificates of insurance, Secretary of State registration documentation or exemption statements, and any applicable service-disabled veteran certifications and ownership verification documentation. The form confirms that successful bidders are required to register with the Oklahoma Secretary of State prior to contract award unless claiming a specific exemption, and must demonstrate compliance with all applicable Oklahoma employment and insurance statutes.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Exhibit_5_OHCA_EGID_Standard_Business_Associate_Agreement.docx | DOCX document | |
| Attachment_B_-_General_Terms.docx | DOCX document | |
| Exhibit_2_Advertising_Approval_Request_Form.docx | DOCX document | |
| omes-form-cp004.docx | DOCX document | |
| Agency_Bidder_Instructions.pdf | ||
| Attachment_D_-_IT_Terms.docx | DOCX document | |
| Exhibit_1_-_Employee_Account_Summary.xlsx | XLSX spreadsheet | |
| Exhibit_6-Third_Party_Supplier_Info.xlsx | XLSX spreadsheet | |
| Exhibit_3-Reference_Sheet.pdf | ||
| Attachment_A.pdf | ||
| Exhibit_4_-_Bidder_Evaluation_Guide.xlsx | XLSX spreadsheet | |
| Attachment_C-_EGID_Agency_Terms.docx | DOCX document | |
| OMES_CP011_-_Amendment_2.docx | DOCX document | |
| OMES_CP011_-_Amendment_1.docx | DOCX document |
Show all 14
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Text version
OMES Form CP076 (11/2024) RESPONDING BIDDER INFORMATION | Page 1 of 1
Central Purchasing
RESPONDING BIDDER INFORMATION
You must submit a Certification for Competitive Bid and Contract along with the response to the solicitation.
1. SOLICITATION
Solicitation #
2. BIDDER GENERAL INFORMATION
FEIN/SSN Supplier ID
Company name
3. BIDDER CONTACT INFORMATION
Address
Contact name Title
Email Phone Website Fax
4. BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL
Yes No
5. REGISTRATION WITH THE OKLAHOMA SECRETARY OF STATE
Yes Filing number:
No Prior to the contract award, the successful bidder is 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 (sos.ok.gov or 405- 521-3911).
6. WORKERS’ COMPENSATION INSURANCE COVERAGE
Bidder is required to provide a certificate of insurance showing proof of compliance with the Oklahoma Administrative Workers’ Compensation Act.
Yes Include a certificate of insurance with the bid.
No Exempt from the Administrative 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. For frequently asked questions concerning workers’ compensation insurance, visit wcc.ok.gov.)
7. DISABLED VETERAN BUSINESS ENTERPRISE ACT
Yes I am a service-disabled veteran business as defined in 74 O.S. § 85.44E.
Include the following with the bid response:
1. Certification of service-disabled veteran status as verified by the appropriate federal agency.
2. Verification of not less than 51% ownership by one or more service-disabled veterans.
3. Verification of the control of the management and daily business operations by one or more service-disabled veterans.
No I do not meet the criteria as a service-disabled veteran business.
8. SIGNATURE
Authorized signature Date
Name Title https://www.sos.ok.gov/ https://www.wcc.ok.gov/
| Central Purchasing |
| RESPONDING BIDDER INFORMATION |
| Solicitation: |
| FEINSSN: |
| Supplier ID: |
| Company name: |
| Contact name: |
| Title: |
| Email: |
| Phone: |
| Website: |
| Fax: |
| 4 BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL: Off |
| Prior to the contract award the successful bidder is required to register with the Secretary of State or must attach a: Off |
| Compensation Act: Off |
| 7 DISABLED VETERAN BUSINESS ENTERPRISE ACT: Off |
| Date: |
| Name: |
| Title_2: |
| Filing number: |
| Address: |
File details come from the government source that posted it. Updated .