TAB_C_Amendment_SBK80014R0003A001.pdf

NSN 7540-01-152-8070 STANDARD FORM 30 (REV. 10-83)

PREVIOUS EDITION UNUSABLE Prescribed by GSA FAR (48 CFR) 53.243

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE PAGE OF PAGES

1 8

2. AMENDMENT/MODIFICATION NO. 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (if applicable)

A001 April 30, 2014

6. ISSUED BY CODE 7. ADMINISTERED BY (if other than item 6) CODE

The Embassy of the United States of America Procurement & Contracting Office Roberta C. Frasurea 71000 Sarajevo Bosnia and Herzegovina

See block 6.

8. NAME AND ADDRESS OF THE CONTRACTOR (No., street, country, State and ZIP Code) (x) 9A. AMENDMENT OF SOLICITATION NO.

SBK80014R0003

9B. DATED (SEE ITEM 11)

April 14, 2014

10A. MODIFICATION OF CONTRACT ORDER

NO.

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbers solicitation is amended as set fourth in item 14. The hour and date specified for receipt of Offers is extended, is not extended. Offer 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 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 ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR 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 THE MODIFICATIONS OF CONTRACTS/ORDERS,

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

(X) A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FOURTH 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 change in paying office, Appropriation data, 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)

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

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

Purpose of this Amendment A001 is to provide update to the Request for Proposal (RFP) SBK80014R0003 and to provide corrections of typographical mistakes found throughout the RFP as per continuation sheet(s) (see enclosed)

This Amendment does not extend time and date for submission of proposals (date and time) specified in the RFP.

Proposals must be submitted on or before 15:00 local time on May 16, 2014 to the address specified in block 9 on the Standard Form 33 and section L of the RFP.

Except as provided herein, all other 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 AND TITLE OF SIGNER (Type or print)

15B. CONTRACTOR/OFFEROR 15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 16C. DATE

SIGNED

BY

(Signature of Person authorized to sign) (Signature of Contracting Officer)

SBK80014R0003

Amendment A001 Page 2 of 8

The Request For Proposal (RFP) SBK80014R0003 is amended to provide an update to the RFP sections and to provide corrections of typographical mistakes found in the RFP as provided below:

Section B - PRICE – HEALTH INSURANCE

1. Prospective offerors shall DISCARD the following pages from the RFP Section B: Page 3 of 60;

Page 4 of 60; Page 5 of 60; Page 6 of 60; and Page 7 of 60. REPLACE these pages with pages provided with this Amendment A001 (see continuation pages), that corrects estimated numbers of employees covered under the RFP

Section J – LIST OF EXHIBITS/ATTACHMENTS

2. Prospective offerors shall DISCARD Page 39 of 60, Section J from the RFP and REPLACE with

Section J provided with Amendment A001 (enclosed) with updated statistics and exhibits.

Correction of typographical mistake in the clause C.1.1.3(b).

3. Clause C.1.1.3(b) is to be DELETED in its entirety and REPLACED with the following clause:

“C.1.1.3.(b) OPTIONAL PLAN (B) Prescription drugs medicines: same as C. 1.1.3(a) OPTIONAL PLAN (A) – above.”

B.2.3. BASE YEAR OF CONTRACT:

Monthly Health Insurance Premium Rate per Employee – BASE PLAN:

Category Estimated Number of Employees

Rate per Employee Total

Single Employees (Self only) 90

Family Plan* 355

SUBTOTAL

* Family Plan – refers to the entire family: employee and eligible dependents.

Total Price for Base Year (Subtotal x 12 months)

B.2.3.1. BASE YEAR OF CONTRACT OPTIONAL PLANS

Monthly Health Insurance Premium Rate per category per plan.

Actual number of employees and families to be enrolled to each optional plan shall be determined after the contract award based on employees interest. The employee participating to any of optional plans shall pay 100% of premium for him/her-self and dependents (family).

OPTIONAL PLAN A – BASE YEAR

Category Monthly Premium Rate per single participant

Single Employees (Self Only)

Family Plan

OPTIONAL PLAN B – BASE YEAR

Category Monthly Premium Rate per single participant

B.2.4. FIRST OPTION YEAR OF THE CONTRACT:

Number of Employees

Total Price for Option Year 1 (Subtotal x 12 months)

B.2.4.1. FIRST OPTION YEAR OF THE CONTRACT OPTIONAL PLANS

Actual number of employees and families to be enrolled to each optional plan shall be determined after the contract award based on employees interest. The employee participating to any of optional plans shall pay 100% of premium for him/her-self and dependents (family).

OPTIONAL PLAN A – FIRST OPTION YEAR

Family Plan*

OPTIONAL PLAN B – FIRST OPTION YEAR

Category Monthly Premium Rate per single participant

B.2.5. SECOND OPTION YEAR OF THE CONTRACT:

Number of Employees

Total Price for Option Year 2 (Subtotal x 12 months)

B.2.5.1. SECOND OPTION YEAR OF THE CONTRACT OPTIONAL PLANS

Actual number of employees and families to be enrolled to each optional plan shall be determined after the contract award based on employees interest. The employee participating to any of optional plans shall pay 100% of premium for him/her-self and dependents (family).

OPTIONAL PLAN A – SECOND OPTION YEAR

OPTIONAL PLAN B – SECOND OPTION YEAR

Category Monthly Premium Rate per single participant

B.2.6. THIRD OPTION YEAR OF THE CONTRACT:

Number of Employees

Total Price for Option Year 3 (Subtotal x 12 months)

B.2.6.1. THIRD OPTION YEAR OF THE CONTRACT OPTIONAL PLANS

Actual number of employees and families to be enrolled to each optional plan shall be determined after the contract award based on employees interest. The employee participating to any of optional plans shall pay 100% of premium for him/her-self and dependents (family).

OPTIONAL PLAN A – THIRD OPTION YEAR

OPTIONAL PLAN B – THIRD OPTION YEAR

Category Monthly Premium Rate per single participant

B.2.7. FOURTH OPTION YEAR OF THE CONTRACT:

Number of Employees

Total Price for Option Year 4 (Subtotal x 12 months)

B.2.7.1. FOURTH OPTION YEAR OF THE CONTRACT OPTIONAL PLANS

Actual number of employees and families to be enrolled to each optional plan shall be determined after the contract award based on employees interest. The employee participating to any of optional plans shall pay 100% of premium for him/her-self and dependents (family).

OPTIONAL PLAN A – FOURTH OPTION YEAR

OPTIONAL PLAN B – FOURTH OPTION YEAR

Category Monthly Premium Rate per single participant

SECTION J

LIST OF EXHIBITS/ATTACHMENTS

Exhibit A – EMPLOYEE STATISTICS Exhibit A – EMPLOYEES AGE

STATISTICS

Number of single Employees 90 Age Female Male

Number of Employees with Family 355 18 – 30 yrs. old 0 0

Family Data 31 – 40 yrs. old 22 80

# of Families w/out eligible children 16 41 – 50 yrs. old 47 225

# of Families with 1 eligible child 135 51 – 60 yrs. old 25 39

# of Families with 2 eligible children 182 61 – 65 yrs. old 2 5

# of Families with 3 eligible children 19 Exhibit B - ELIGIBLE SPOUSES AGE STATISTICS

# of Families with ≥ 4 eligible children 3 Age Female Male

Exhibit B – ORE EMPLOYEES STATISTICS 18 – 30 yrs. old 6 0

Number of single Employees 0 31 – 40 yrs. old 158 5

Number of Employees with Family 3 41 – 50 yrs. old 118 29

ORE Family Data 51 – 60 yrs. old 21 15

# of Families w/out eligible children 0 61 – 65 yrs. old 9 4

# of Families with 1 eligible child 0 Exhibit C - ELIGIBLE CHILDREN AGE STATISTICS

# of Families with 2 eligible children 3 Age Female Male

# of Families with 3 eligible children 0 0 – 5 yrs. old 50 51

# of Families with ≥ 4 eligible children 0 6 – 14 yrs. old 140 146

Exhibit C – RETIREES RIDERS STATISTICS 15 – 18 yrs. old 48 49

Number of single Employees 1 19 – 26 yrs. old 45 39

Number of Employees with Family 0 >26 yrs. old 0 0

ORE Family Data

# of Families w/out eligible children 0

# of Families with 1 eligible child 0

# of Families with 2 eligible children

# of Families with 3 eligible children 0

# of Families with ≥ 4 eligible children 0

LIST OF ATTACHMENTS

1. Letter from Bosnia and Herzegovina Republic of Srpska, Ministry of Health and Social Welfare, Ref.

No. 11/01-052-44/14 (attached as separate document) … 1 page

2. Letter from Bosnia and Herzegovina Federation of Bosnia and Herzegovina Federal Ministry of

Health, Ref. No: 01-37-2063/14 (attached as separate document) … 1 page