191D3222R0016 A002 Post Jakarta SAM.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

CONTRACT ID CODE

PAGE OF PAGES

1 7

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

SEE BLOCK 16C

4. REQUISITION/PURCHASE REQ. NO.

5. PROJECT NO. (If applicable)

6. ISSUED BY CODE

GSO/PCU

7. ADMINISTERED BY (If other than Item 6)

CODE

American Embassy Jakarta Tel. (62-21) 3435-9080 Fax (62-21) 3435-9910

8. NAME AND ADDRESS OF CONTRACTOR (NO., street, city, county, State, and ZIP Code)

9a. AMENDMENT OF SOLICITATION NO.

191D3222R0016

9b. DATED (SEE ITEM 11) August 15, 2022

10a. MODIFICATION OF CONTRACT/ORDER NO.

10b. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning ____1___ copies of the amendment;(b) By acknowledging receipt of this amendment on each copy of the offer submitted; or(c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying Office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b)

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) To exercise option year 2

E. IMPORTANT: Contractor is not, is required to sign this document and return ____1____ copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

The purpose of this amendment is to extend the offer due date and to revise the pricing tables, to replace several exhibits and to add an additional exhibit in Section J.

1. The date for the of submission of proposals is hereby extended, from October 5 to Tuesday, October 31, 2022,

12.00 noon local time.

SEE CONTINUATION SHEETS

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

16A. NAME OF CONTRACTING OFFICER

ARTHUR DYMOND

15B. NAME OF CONTRACTOR/OFFEROR

BY

(Signature of person authorized to sign)

15C.DATE SIGNED 16B. UNITED STATES OF AMERICA

/s/ ARTHUR DYMOND (Signature of Contracting Officer)

16C.DATE SIGNED

U.S. Embassy Jakarta 191D32-22-R0016 Heath Insurance Amendment 0002

2. The pricing tables in Section B, paragraphs B.2.4, B.2.5, B.2.6, B.2.7, B.2.8 and B.29 are hereby rescinded and replaced with the following paraphs.

B.2.4 BASE YEAR OF THE CONTRACT

Bi-Weekly Rates Per Premiums

Category Estimated Number of Premiums*

Rate per Premium Extended Bi-Weekly Total

a. Male Employee & Spouse

b. Female Employee & Spouse over 45 years old

c. Female Employee & Spouse under 45 years old

d. Child 1916 Subtotal (a+b+c+d) TOTAL PRICE FOR BASE YEAR(d x 26)**

*estimated number of premiums does not include any Riders (B.1.1) **does not include any premiums for Riders.

Rider Category*** Biweekly Rate per Premium C.1.1.21 Excess Coverage

***not included in the Total Price for Base Year Calculation

B.2.5 FIRST OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium Extended Bi-Weekly Total

e. Male Employee & Spouse

f. Female Employee & Spouse over 45 years old

g. Female Employee & Spouse under 45 years old

h. Child 1916 Subtotal (a+b+c+d) TOTAL PRICE FOR FIRST OPTION (d x 26)**

***not included in the Total Price for First Option Year Calculation

B.2.6 SECOND OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium

Extended Bi-Weekly Total

i. Male Employee & Spouse

j. Female Employee & Spouse over 45 years old

k. Female Employee & Spouse under 45 years old

l. Child 1916

TOTAL PRICE FOR SECOND OPTION (d x 26)**

***not included in the Total Price for Second Option Year Calculation

B.2.7 THIRD OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium

Extended Bi-Weekly Total

m. Male Employee & Spouse

n. Female Employee & Spouse over 45 years old

o. Female Employee & Spouse under 45 years old

p. Child 1916

TOTAL PRICE FOR THIRD OPTION (d x 26)**

*** not included in the Total Price for Third Option Year Calculation

B.2.8 FOURTH OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium Extended Bi- Weekly Total

q. Male Employee & Spouse

r. Female Employee & Spouse over 45 years old

s. Female Employee & Spouse under 45 years old

t. Child 1916

TOTAL PRICE FOR FOURTH OPTION (d x 26)**

***not included in the Total Price for Fourth Option Year Calculation

B.2.9 GRAND TOTAL HEALTH INSURANCE FOR BASE PLUS ALL OPTION YEARS

Base Year Total First Option Year Total Second Option Year Total Third Option Year Total Fourth Option Year Total

Grand Total of Base Plus All Option Years

3. In Section J, Exhibit A, Exhibit B, and Exhibit C are hereby rescinded and replaced with the revised Exhibit A, Exhibit B, Exhibit C and Exhibit F is hereby added.

SECTION J

LIST OF EXHIBITS/ATTACHMENTS

EXHIBIT A: EMPLOYEE AND DEPENDENT STATISTICS:

Agency Male

Employee/Spouse

Female employee/spouse ≥ 45 years of age

Female employee/spouse <

45 years of age

Child

Dept. of State - Jakarta 372 124 261 531

GUARD/DS/JKT 400 105 284 781

U.S. Consulate - Medan 30 4 28 59

OBO MEDAN 19 1 13 28

U.S. Consulate General - Surabaya 152 36 120 282

U.S. Consular Agency - Bali 6 4 4 6

USAID 72 43 46 103

FAS 8 4 4 8

FCS 9 9 4 11

DAO 6 2 4 3

DOJ 8 5 5 11

LOC 32 18 15 42

ODC 7 8 8 9

DS/ATA 8 3 8 15

CDC 4 1 3 4

IBB/VOA 3 4 0 6

EXBS 2 1 1 4

PEPFAR 1 1 0 0

NAVFAC 1 0 1 1

DHS 2 1 3 4

DEA 3 2 2 6

FPD 3 4 1 2

INL 2 0 4 1

MCC 1 1 0 0

TOTAL 1151 381 819 1916

EXHIBIT B: EMPLOYEE AND DEPENDENT STATISTICS – BREAKDOWN ACCORDING TO AGE

AND GENDER

Age Bracket Employee Spouse Child

M F M F M F

0-5 149 138

5-10 238 232

10-15 280 253

15-20 230 221

20-25 3 1 0 3 85 90

25-30 29 9 3 35 1 0

30-35 60 43 9 115

35-40 177 64 29 218

40-45 275 79 39 214

45-50 214 91 49 170

50-55 136 32 33 76

55-60 72 20 15 30

60-65 6 0

65-70 1 0

ABOVE 70

SUBTOTAL 966 339 184 861 983 934

EXHIBIT C: ORE EMPLOYEES AND DEPENDENTS RIDER

Agency Male Employee/Spouse

Female employee/spouse ≥ 45 years of age

Female employee/spouse < 45 years of age

Child

ORE CMR 4 3 2 10

ORE DCMR 2 1 2 5

ORE ASEAN 3 1 2 5

ORE SBY 1 0 1 2

ORE MEDAN 1 1 1 0

TOTAL 11 6 8 22

EXHIBIT F: THE TOTAL NUMBER OF PARTICIPANTS FOR EACH YEAR.

YEAR TOTAL PARTICIPANTSs

August 2017 – July 2018 4496

August 2018 – July 2019 4535

August 2019 – July 2020 4456

August 2020 – July 2021 4402

August 2021 – April 2022 4476