Payment of Employee Health Care Expenses Certification Form.pdf
PDF 599 KB Posted
- Attached to
- SHORELINE RESTORATION AT FSK POLICE HEADQUARTERS
- Solicitation number
- BPM057212
- Issued by
- Baltimore County, Maryland
About this file
This is a Payment of Employee Health Care Expenses Certification Form required under Maryland State Finance & Procurement Article Title 17, Subtitle 8, applicable to bidders and subcontractors on state and local contract opportunities in Maryland, including the Shoreline Restoration project at FSK Police Headquarters in Baltimore County. The certification form must be completed by an authorized representative of the bidding firm or subcontractor to confirm compliance with employee health care expense requirements for all employees who will work on or at the project site. The form requires the bidder to select one of four compliance options: paying aggregate employee health care expenses of at least 5% of aggregate social security wages; paying 50% or more of the required premium for credible health insurance plan coverage; paying some portion of health care expenses under a credible health insurance plan or collective bargaining agreement with affirmation of future compliance; or demonstrating exemption status with 30 or fewer employees.
The certification must be signed and dated by an authorized representative and include the company name, title of the authorized representative, and complete company address. Submission of false information regarding these health care expense requirements subjects the bidder or subcontractor to civil penalties ranging from $2,500 to $25,000 per violation under Maryland Annotated Code Section 17-804. This form is a mandatory compliance document that must accompany bid submissions for state and local contract opportunities in Maryland.
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Text version
KB-3022-0000
Payment of Employee Health Care Expenses Certification
Under State Finance & Procurement Article Title 17, Subtitle 8
In connection with Solicitation Number _________I, _______[Name]______________ hereby certify that __[Firm Name]_______ is ☐ the bidder/☐ a subcontractor on this project (indicate whether the firm is the bidder or a subcontractor). I further certify that, with respect to employees who will work on or at the site of the project:
[CHOOSE ONLY ONE OPTION BELOW. Note that for purposes of this Certification, “Credible Health Insurance Plan” means any group policy, contract, or program that is written or administered by a disability insurer, health care service plan, fraternal benefits society, self-insured employer plan, or any other entity, in the state of Maryland or elsewhere, that arranges or provides medical, hospital, and surgical coverage not designated to supplement other private or governmental plans.]
1. ☐ The firm pays aggregate employee health care expenses of at least 5% of the aggregate social security wages paid;
OR
2. ☐ The firm pays 50% or more of the required premium necessary to obtain employee coverage by a credible health care insurance plan (as defined above).
[PRIOR TO JULY 1, 2021, THE FOLLOWING OPTION IS ALSO AVAILABLE]
3. ☐ The firm pays some portion of employee health care expenses under a contract with a credible health care insurance plan (as defined above) or through a collective bargaining agreement; and we affirm that our firm will meet the requirements of Option 1 or 2 above upon renewal of the contract or collective bargaining agreement.
4. ☐ The firm has 30 or fewer employees, and therefore exempt.
Further, I acknowledge that under §17-804 of the State Finance and Procurement Article, Maryland Annotated Code, a person or entity providing false information regarding this requirement may be subject to a civil penalty of not less than $2,500 and not exceeding $25,000 for each violation.
Signature of Authorized Representative Date
Title of Authorized Representative
Company Street Address
City, State, ZIP Code
File details come from the government source that posted it. Updated .