RFP 2025-1600-0123 Submittal Forms A-F.docx

STATE OF ALASKA

RFP 2025-1600-0123

SUBMITTAL FORM A – Offeror Information

PROJECT INFORMATION

RFP NUMBER:

PROJECT NAME:

OFFEROR INFORMATION

Company Name:

Address:

Tax ID:

Alaska Business License #:

CONTACT INFORMATION

Provide contact information for the individual that can be contacted for clarification regarding this proposal:

Name

Title

Address

Email

Telephone

Procurement Officer Note: REVISE OR DELETE AS REQUIRED.

CRITICAL TEAM MEMBERS

Provide the names of all critical team members that will be assigned to this contract (add as necessary). Note: These individuals cannot be removed or replaced from this project, or their positions, unless approved in writing the project director or procurement officer.

Primary Project Manager

Name and Title of Position 2

Name and Title of Position 3

Name and Title of Position 4

Name and Title of Position 5

ADDENDA ACKNOWLEDGEMENT

The offeror acknowledges receipt of the following amendments and has incorporated the requirements of such amendments into their proposal. Failure to identify and sign for all amendments may subject the offeror to disqualification. The offeror must list all amendments (by number), then initial and date to confirm that you have received and incorporated them into your proposal (add more rows as necessary).

CERTIFICATIONS

* Failure to answer or answering “False” may be grounds for disqualification. For any “False” responses, provide clarification (up to 250 word maximum for each “False” clarification) below (add rows as necessary).

CONFLICT OF INTEREST STATEMENT

Indicate below whether or not the firm or any individuals that will work on the contract has a possible conflict of interest (e.g., currently employed by the State of Alaska or formerly employed by the State of Alaska within the past two years) and, if so, the nature of that conflict. The procurement officer reserves the right to consider a proposal non-responsive and reject it or cancel the award if any interest disclosed from any source could either give the appearance of a conflict or cause speculation as to the objectivity services to be provided by the offeror.

* Failure to answer may be grounds for disqualification.

If “Yes”, please provide additional information regarding the nature of that conflict:

ALASKA PREFERENCES

If you wish to claim any Alaska Preferences, please complete the Alaska Bidder Preference Certification Form that follows the below signature section.

SIGNATURE

This proposal must be signed by a company officer empowered to bind the company.

Printed Name

Title

Date

Signature

ALASKA BIDDER PREFERENCE CERTIFICATION

AS 36.30.321(A) / AS 36.30.990(2)

BUSINESS NAME: Click or tap here to enter text.

Please list any additional Alaska Preferences below that you believe your firm qualifies for.

1. 2. 3. 4. 5. 6.

To qualify for and claim the Alaska Bidder Preference you must answer YES to all questions below in the Alaska Bidder Preference Questions section.

To qualify for and claim the Alaska Veteran Preference or the Alaska Military Skills Program Preference, you must answer also answer YES to the questions in those respective sections. A signed copy of this form must be included with your bid or proposal no later than the deadline set for receipt of bids or proposals.

If you are submitting a bid or proposal as a JOINT VENTURE, all members of the joint venture must complete and submit this form before the deadline set for receipt of bids or proposals. AS 36.30.990(2)(E)

If the procuring agency is unable to verify a response, the preference may not be applied. Knowingly or intentionally making false or misleading statements on this form, whether it succeeds in deceiving or misleading, constitutes misrepresentation per AS 36.30.687 and may result in criminal penalties.

Alaska Bidder Preference Questions:

1) Does your business hold a current Alaska business license per AS 36.30.990(2)(A)?

☐ YES ☐ NO

If YES, enter your current Alaska business license number: Click or tap here to enter text.

If YES, please complete the following information:

A. Physical Place of Business

“Place of business” is defined as a location at which normal business activities are conducted, services are rendered, or goods are made, stored, or processed; a post office box, mail drop, telephone, or answering service does not, by itself, constitute a place of business per 2 AAC 12.990(b)(3).

Do you certify that the Place of Business described in Question 3A meets this definition?

☐ YES ☐ NO

B. The bidder or offeror, or at least one employee of the bidder or offeror, must be a resident of the state under AS 16.05.415(a) per 2 AAC 12.990(b)(7).

1) Do you certify that the bidder or offeror OR at least one employee of the bidder or offeror is physically present in the state with the intent to remain in Alaska indefinitely and to make a home in the state per AS 16.05.415(a)(1)?

☐ YES ☐ NO

2) Do you certify that that the resident(s) used to meet this requirement has maintained their domicile in Alaska for the 12 consecutive months immediately preceding the deadline set for receipt of bids or proposals per AS 16.05.415(a)(2)?

☐ YES ☐ NO

3) Do you certify that the resident(s) used to meet this requirement is claiming residency ONLY in the state of Alaska per AS 16.05.415(a)(3)?

☐ YES ☐ NO

4) Do you certify that the resident(s) used to meet this requirement is NOT obtaining benefits under a claim of residency in another state, territory, or country per AS 16.05.415(a)(4)?

If YES, enter your current Alaska corporate entity number: Click or tap here to enter text.

Please identify each member by name: Click or tap here to enter text.

Please identify each member by name: Click or tap here to enter text.

Alaska Veteran Preference Questions:

1. Per AS 36.30.321(f), is your business:

A. A sole proprietorship owned by an Alaska veteran?

Per AS 36.30.321(F)(3) “Alaska veteran” is defined as an individual who:

(A) Served in the

(i) Armed forces of the United States, including a reserve unity of the United States armed forces; or

(ii) Alaska Territorial Guard, the Alaska Army National Guard, the Alaska Air Nations Guard, or the Alaska Naval Militia; and

(B) Was separated from service under a condition that was not dishonorable.

Do you certify that the individual(s) indicated in Question 1A, 1B, 1C, or 1D meet this definition and can provide documentation of their service and discharge if necessary?

☒ YES ☐ NO

Alaska Military Skills Program Preference Questions:

1) Per AS 36.30.321(l), does your business:

A. Employ at least one person who is enrolled in, or within the past two years, graduated from, a United States Department of Defense SkillBridge or United States Army career skills program that offers civilian work experience through specific industry training, pre-apprenticeships, registered apprenticeships, or internships during the last 180 days before a service member separates or retires from the service; or

SIGNATURE

By signature below, I certify under penalty of law that I am an authorized representative of Click or tap here to enter text. and all information on this form is true and correct to the best of my knowledge.

Printed Name

Title

Date

Signature

SUBMITTAL FORM B – Experience and Qualifications SPECIAL REQUIREMENTS: This Submittal Form must not identify the offeror’s proposed costs and must not exceed eight pages (reference RFP section 4.02).

SUBMITTAL FORM C – General Methodology & Management Plan SPECIAL REQUIREMENTS: This Submittal Form must not identify the offeror’s proposed costs and must not exceed six pages (reference RFP section 4.02).

SUBMITTAL FORM D – Example Project Management Plan SPECIAL REQUIREMENTS: This Submittal Form must not identify the offeror’s proposed costs and must not exceed six pages (reference RFP section 4.02).

SUBMITTAL FORM E – Mandatory Requirements

The following are mandatory requirements. The offeror must confirm they meet each requirement and provide an explanation (up to 500 word maximum for each requirement) in the Explanation section at the end of this document to demonstrate their acknowledgement and how they meet each related requirement. A “No” selection or failure to provide an explanation will cause the proposal to be deemed non-responsive. Make sure to indicate start and end dates for any requirements that have time requirements and provide sufficient detail to ensure the procurement officer can adequately determine the requirements are met.

Mandatory Requirements

a. Be a certified member of the American Academy of Actuaries, and a certified Fellow or Associate of the Society of Actuaries (copies of the required certifications must be provided upon request); and, Have at least three (3) years of experience as a health care actuary within the past five (5) years.

□ Yes □ No

Explanation

1.

2.

3.

4.

5.

6.

SUBMITTAL FORM F – Subcontractors

Please complete the below form if using subcontractors. During contract negotiation, the state may require a signed written statement from each subcontractor that clearly verifies the subcontractor is committed to performing the services required by the contract. Prior to contract award, the state will also require evidence that a subcontractor possesses a valid Alaska business license if they will be performing work within Alaska.

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