Sensitive_Security_Information_Acknowledgement_Form.docx

DOCX document 20 KB Posted

Attached to
Worker's Compensation Third Party Administration (TPA) Claims Management Services
Solicitation number
RFP PS-27-0005
Issued by
Maricopa County, Phoenix City, Arizona

About this file

This is a Sensitive Security Information Acknowledgement Form related to the City of Phoenix's procurement of Worker's Compensation Third Party Administration (TPA) Claims Management Services in Arizona. The solicitation seeks sealed offers for comprehensive third-party administration claims management services, with an effective date upon final signature and recording by the City Clerk's department. The agreement commencement date is July 1, 2027, or the effective date, whichever is later. The contract term is five years beginning on the commencement date with no options to extend. Offerors may access the solicitation through the City's Procurement Portal and should direct technical support questions to the support feature or procurement-support@opengov.com, while other solicitation-related inquiries should be directed to the listed procurement officer. The agreement will terminate upon the earliest occurrence of reaching the end of the five-year term or upon termination pursuant to agreement provisions.

The file itself appears to be an acknowledgement form designed to ensure that individuals handling sensitive security information understand their obligations regarding confidentiality and proper handling of such materials. This form is a standard compliance document typically required during procurement processes involving sensitive information, ensuring that bidders and their personnel acknowledge awareness of security protocols and restrictions related to the contract opportunity.

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Text version

EXHIBIT __

City of Phoenix Aviation Department Sensitive Security Information Acknowledgement Form

The documents entitled [fill in document title(s)] (“Documents”) to be used as part of the [fill in project name] contain Sensitive Security Information that is controlled under 49 C.F.R. Parts 15 and 1520. These documents may only be disclosed to persons who have the requisite “need to know”, as defined in 49 C.F.R. Parts 15 and 1520. Unauthorized release of this information may result in civil penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 C.F.R. Parts 15 and 1520.

I acknowledge, on my behalf and that of my company, the above statement and agree to destroy the [fill in document title(s)], in compliance with 49 C.F.R. Parts 15 and 1520, upon the earlier of our company’s completion of our need to review and/or use the Documents or no later than [fill in current contract end date].

NAME OF COMPANY

AUTHORIZED REPRESENTATIVE PRINTED NAME

AUTHORIZED REPRESENTATIVE’S SIGNATURE

______
TITLEPHONE NUMBER

ADDRESS CITY, STATE AND ZIP CODE

File details come from the government source that posted it. Updated .