Response Form A~13.pdf

RESPONSE FORM A - BID RESPONSE SHEET

DRM 2026-37 New Dialysis Room

Before submitting this and all other forms associated with this solicitation, all Bidders are advised to check the solicitation record on www.COMMBUYS.com for the final versions of all forms.

All Bidders must complete and return this Attachment with their response in order to be considered responsive. Completing every section of this document fully is mandatory unless instructions for specific questions state otherwise.

Section 1- Contact Information

Company Information Use this column for the answer

Company name

Street address, city, state, zip

Main phone number

Toll-free phone number

Fax number

Website

Contract Manager Use this column for the answer

Name, Title

Phone number

Fax

Email

Contact for Placing Orders (if different)

Use this column for the answer

Name, Title

Phone number (working hours)

Phone number (non-working hours)

Fax

Email http://www.commbuys.com/

Section 2. Checklist of Required Documentation

Omission of required information or documentation may be grounds for Bidder disqualification. To ensure accurate review of your submission, please follow the file naming conventions and use the provided wording for the “Response Description” field.

Required Document Instructions Mark with “X” if done

Response Form A (this document) Complete electronically and submit with response.

File name: Response Form A_[your company name] Response description: Response Form A

Proposal Pricing

Complete electronically and submit with response.

File name: Proposal_[your company name] Response description: Proposal Pricing

Certificates of Insurance See Section 4.12 of the RFR

Combine in one file and submit with response.

File name: Insurance_[your company name] Response description: Copies of Insurance

Warranty Documentation Provide all warranty documentation per RFR (If applicable)

Combine in one file and attach to response.

File name:Wnty_[your company name] Response description: Warranty Information

Prompt Pay Discount Form Complete electronically and submit with response.

File name: PPD_[your company name] Response description: PPD

Business Reference Form Complete electronically and submit with response.

File name: BRF_[your company name] Response description: BRF

Additional Environmentally Preferable Products/Practices

Complete electronically and submit with response.

File name: EPP_[your company name] Response description: EPP

OSHA-10 Certificates Combine in one file and attach to response.

File name: OSHA10_ (your company name) Response description: OSHA

50% Payment Bond if total contract is >$25,000.

Combine in one file and attach to response.

File name: PB_(your company name) Response description: PB

Company Information:

Business Background. Bidders must provide a brief description of your business and business background. Limit: 1 page.

Use the box below for the answer

Basic Information

Use this column for the answer or attach additional documentation

Number of years in business prior to the due date of this solicitation

Has the company had a previous Tax ID? What was the company’s past name?

Was this the result of a merger or acquisition? Please define with the dates of this circumstance.

Number of years in business offering each category that your company is submitting a response.

Corporate Headquarters location.

Business hours/days

Industry Experience. Bidders must provide a brief description of your company’s experience in the business of installing new water process piping systems. Limit: 1 page.

Locations. List your firm’s locations/offices, number of employees and the phone number.

# Location Address Phone Number

Insurance. Describe your company’s liability (general and auto), property, personal injury, and worker’s compensation insurance, including the limits, in the box below. Submit certified copies of insurance.

Total Limit Per Incident Limit

General liability

Auto

Worker’s Compensation

Professional Liability

Personal injury

Security Liability (Cyber Liability)

Financial Stability

Litigation, Penalties, Pending Actions, Enforcement Actions, or Bankruptcy: The bidder shall submit a description of any and all investigations, indictments or pending litigation by any federal, state or local jurisdiction relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related company. A list of all criminal convictions within the last five years relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all civil penalties, judgments, consent decrees and other sanctions within the last five years, as a result of any violation of any law, rule, regulation or ordinance in connection with its business activities relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all actions occurring within the last five years which have resulted in revocation or suspension of any permit or authority to do business in any jurisdiction relating to the submitting entity, any officer, director, partner or member thereof, any affiliate or any related entity. A list of all actions occurring within the last five years that have resulted in the barring from public bidding relating to the bidder, an officer, director, partner or member thereof, any affiliate or any related entity. A list of all pending actions and enforcement actions, including OSHA violations. A list of all bankruptcy and other similar proceedings within the past five years relating to the bidder, any officer, director, partner or member thereof, any affiliate or any related entity.

Defaults: The bidder shall provide a description, in detail, of any situation in which the bidder’s firm (either alone or as part of a joint venture), or a subsidiary of the bidder’s firm, defaulted or was deemed to be in noncompliance of any contractual obligations, explaining the situation, its outcome and all other relevant facts associated with the event described. Please also provide the name, title and telephone number of the principal manager of the contract user who asserted the event of default or noncompliance.

Other Adverse Situations: The bidder shall provide a description of any present facts known to the bidder that might reasonably be expected to affect adversely either its ability to perform any aspect of the agreement or the viability of any affiliated entity that might reasonably be expected to supply financial support.

Use this column for the answer

Describe any Litigation, Penalties, or Bankruptcy

Describe any Defaults

Describe any other Adverse Conditions

Describe any actions, pending actions, enforcement actions or violations

Recalls. Describe in detail your company’s procedure for recalls. (You may attach policy and place see attached below)

Return Policy. Describe in detail your company’s written return policy. (You may attach policy and place see attached below)

Warranties (Manufacture, Extended & Service). State your company’s warranties that your company is submitting a response. (you may attach policy and place see attached below)

Installation. Is installation provided? If so please list any special requirements. (You may attach policy and place see attached below Limit: 1 page.

Subcontractor Disclosure. Please copy and paste additional copies of the table below for more subcontractors. Each subcontractor is subject to individual SST approval.

Company Information Use this column for the answer

Company name

Street address, city, state, zip

Main phone number

Toll-free phone number

Fax number

Website

Products / Services this Subcontractor intends to provide under the Contract (if approved)

Value Added Services (for all categories). Please describe any value-added services provided by your company that are relevant to the scope of your response to this RFR. Limit: 1 page.

Discounts Available

Please describe any and all discounts offered by your company, as follows:

Prompt Pay Discounts (PPD)

Please provide your companies Prompt Payment Discount. Formal form to follow upon award if a PPD is offered.

Prompt Payment Discount % Payment Issue Date w/in

% 10 Days

% 15 Days

% 20 Days

% 30 Days

Special Purchases

All Special Purchases are to be defined below.

Additional Discounts Available

Any additional discounts available are to be defined below.

4.14 Price Benchmarking

Please describe any price agreements you may have with the U.S. Federal Government (e.g. General Services Administration), national public purchasing cooperatives (e.g. US Communities, NJPA, etc.), local purchasing cooperatives (e.g. chemical buying consortiums), or other states or large public organizations within the Commonwealth of Massachusetts. How does the pricing proposed by your company under this contract compare to pricing offered under agreements with above-mentioned organizations. Limit: 1 page.

Use this column for the answer

U.S. Federal Government (e.g.

General Services Administration)

Do you have a current contract with this type of organization? (Yes/No):

If Yes, name the organization(s) supplied under that contract:

If Yes, please compare the pricing offered under that contract with the pricing proposed to the Commonwealth in response to that solicitation:

National public purchasing cooperatives (e.g. US Communities, NJPA, etc.)

Do you have a current contract with this type of organization? (Yes/No):

If Yes, name the organization(s) supplied under that contract:

If Yes, please compare the pricing offered under that contract with the pricing proposed to the Commonwealth in response to that solicitation:

Local purchasing cooperatives (e.g. the Massachusetts Higher Educational Consortium)

Do you have a current contract with this type of organization? (Yes/No):

If Yes, name the organization(s) supplied under that contract:

If Yes, please compare the pricing offered under that contract with the pricing proposed to the Commonwealth in response to that solicitation:

Other states or large public organizations within the

Do you have a current contract with this type of organization? (Yes/No):

If Yes, name the organization(s) supplied under that contract:

Commonwealth of Massachusetts

If Yes, please compare the pricing offered under that contract with the pricing proposed to the Commonwealth in response to that solicitation:

Certification

I , ___________________________________, agree to all terms, conditions and requirements stated in this RFR. I realize failure to comply with any requirement of this RFR after contract award may result in termination of an awarded contract.

Signed electronically Authorized officer name:

Title:

Date: