Solicitation_Attachments-Event_18460.pdf

Rev. April 2025

ATTACHMENT A: RESPONDER DECLARATIONS

The undersigned certifies, to the best of his or her knowledge and belief, that:

A. Response Contents. The information provided is true, correct, and reliable for purposes of evaluation for potential contract award. The submission of inaccurate or misleading information may be grounds for disqualification from the award as well as subject the Responder to suspension or debarment proceedings as well as other remedies available by law

B. Authorized Signature. This Declaration is signed by the appropriate person(s), with the authority to contractually bind the Responder, as required by applicable articles, bylaws, resolutions, minutes, and ordinances.

C. Non-Collusion Certification.

1. The Proposal has been arrived at by the Responder independently and has been submitted without collusion and without any agreement, understanding or planned common course of action with any other vendor designed to limit fair or open competition; and

2. The contents of the Response have not been communicated by the Responder or its employees or agents to any person not an employee or agent of the Responder and will not be communicated to any other individual prior to the due date and time of this Solicitation. Any evidence of collusion among Responders in any form designed to defeat competitive responses will be reported to the Minnesota Attorney General for investigation and appropriate action.

D. Organizational Conflicts of Interest. To the best of Responder’s knowledge and belief, and except as otherwise disclosed, there are no relevant facts or circumstances which could give rise to an organizational conflict of interest.

An organizational conflict of interest exists when, because of existing or planned activities or because of relationships with other persons,

1. a vendor is unable or potentially unable to render impartial assistance or advice to the State;

2. the vendor’s objectivity in performing the contract work is or might be otherwise impaired; or

3. the vendor has an unfair competitive advantage.

If after award, an organizational conflict of interest is discovered, an immediate and full disclosure in writing must be made to the State’s Chief Procurement Officer which must include a description of the action which the contractor has taken or proposes to take to avoid or mitigate such conflicts. If an organizational conflict of interest is determined to exist, the State may, at its discretion, cancel the contract. In the event the Contractor was aware of an organizational conflict of interest prior to the award of the contract and did not disclose the conflict to OSP, the State may terminate the contract for default. Organizational conflicts of interest terms apply to any subcontractors for this work.

E. Certification Regarding Lobbying. For State of Minnesota Contracts and Grants over $100,000, the undersigned certifies, to the best of his or her knowledge and belief that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, Disclosure Form to Report Lobbying in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into and is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352.

Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

F. Copyrighted Material Waiver. By signing its Response, the Responder certifies that it has obtained all necessary approvals for the reproduction and distribution of the contents of its response.

G. Diverse Spend Reporting. The Sample Contract contains a clause for Diverse Spend Reporting. When this clause applies, Contractor will be required to register in a free portal to report diverse spend.

Please see Diverse Spend Reporting Frequently Asked Questions for additional information.

By signing this form, Responder acknowledges and certifies compliance with all applicable requirements indicated above.

Company Name:

Signature:

Printed Name:

Title:

Date:

Phone Number:

Email Address:

https://osp.admin.mn.gov/sites/osp/files/2022-11/viva_diverse_spend_reporting_faq.pdf

ATTACHMENT B: EXCEPTIONS TO STATE’S TERMS AND CONDITIONS

The State presumes a responder agrees to the terms and conditions of this solicitation unless a responder takes specific exception to one or more of the conditions on this form.

The State reserves the right to reject, negotiate, or accept any exception listed to the State’s terms and conditions (including those found in the attached Sample Contract).

INSTRUCTIONS: A responder must explicitly list all exceptions to State’s terms and conditions, if any (including those found in the attached Sample Contract). Reference the clause number and page number of the State's term and condition for each of a responder’s exceptions. If no exceptions exist, state "NONE" specifically on the form below.

Whether or not exceptions are taken, the Responder must sign and date this form and submit it as part of their response. (Add additional pages if necessary.)

Clause and Page Number Suggested Change to Clause Explanation or Justification

By signing this form, I acknowledge that the above-named responder accepts, without qualification, all terms and conditions stated in this solicitation (including the sample contract) except those clearly outlined as exceptions above.

This acknowledgement includes acceptance of the section of the Sample Contract, Exhibit A, titled “Contractor’s Documents.”

Signature:

Printed Name:

Title:

Date:

ATTACHMENT C: COST DETAIL

1. Cost Proposal. Responders must download and use Exhibit D Eyeglass Price Schedule attached to this Solicitation.

The Exhibit D Eyeglass Price Schedule must be completed by the Responder and uploaded with your solicitation response. If pricing is not returned with your solicitation response, your response will be rejected. Failure to use Exhibit D Eyeglass Price Schedule may be cause for rejection. Responders must provide a price for all line items available on the Exhibit D to be considered for an award.

2. Alterations or Erasures. The State reserves the right to reject a response containing an alteration or erasure of any price used to determine the lowest responsible responder unless the alteration or erasure is done in a manner that is clear and authenticated by an authorized representative of the Responder. An acceptable way to make an alteration or erasure is to cross out the price, print the correction in ink adjacent to it, and have an authorized representative of the Responder initial and date that correction.

ATTACHMENT D: RESPONDER FORMS Workforce and Equal Pay Declaration Page

This form is required for all businesses executing government contracts under the following:

Select one:

☐ Businesses executing a contract with State or Metropolitan agencies in excess of $100,000 (Workforce Certificate) and if applicable $500,000 (Equal Pay Certificate)

☐ Businesses executing a contract with University of Minnesota for general obligation bond funded capital projects in excess of $100,000 (Workforce Certificate) and if applicable $500,000 (Equal Pay Certificate)

☐ Businesses executing a contract with Political Subdivisions for general obligation bond funded capital projects in excess of $250,000 (Workforce Certificate) and if applicable $1,000,000 (Equal Pay Certificate)

Select all that apply:

We are a Certificate holder:

☐ Workforce Certificate under the name: _________________________________________________________ ☐ Equal Pay Certificate under the name: __________________________________________________________

We are applying/have applied for the following certificate(s):

☐ Workforce Certificate Application date (MM/DD/YYYY): ____________________ ☐ Equal Pay Certificate Application date (MM/DD/YYYY): ____________________

We have not applied for one or both certificates:

☐ Our Company does not yet have a Workforce Certificate or Equal Pay Certificate. We acknowledge that a

Workforce and, if applicable, Equal Pay Certificate, or approved exemption by MDHR is required before a contract can be executed.

We are Exempt:

☐ We attest to MDHR that we have not employed 40 or more employees on a single day during the prior 12 months in Minnesota or the state in where we have our primary place of business. MDHR may request the names of our employees during the previous 12 months, the date of separation, if applicable, and the current employment status and count.

Business Information

Vendor/Supplier ID Business Name Name of Contracting Agency

Authorized Signatory Name Title Date

Signature Email Phone

For assistance with this form, email the Minnesota Department of Human Rights Compliance.MDHR@state.mn.us https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/

ATTACHMENT E: ADDITIONAL INFORMATION

1. Contractor’s Contact Information. Provide the contact information for the representative responsible for the management of the contract and the representative receiving purchase orders.

Vendor’s Legal Name

Address

Contact Person (Contract)

Email Address

Telephone Number

Contact Person (PO Order)

Email Address

Telephone Number

2. Prompt Pay Discount. What prompt pay discounts do you offer? Select all that apply, if “other,” specify terms in the comment section below:

□ 1% in 30

□ 2% in 30

□ 3% in 30

□ 1% in 10, Net 30

□ 2% in 10, Net 30

□ 3% in 10, Net 30

□ 5% in 10, Net 30

□ Other

□ 1% in 15, Net 30

□ 2% in 15, Net 30

□ 3% in 15, Net 30

□ 1% in 20, Net 30

□ 2% in 20, Net 30

□ 3% in 20, Net 30

□ Net 30

Comments:

3. Delivery Time Frame. Responder must enter a delivery time frame after receipt of order (ARO) in the space below.

Rev. 12/19 Page 7 of 16

ATTACHMENT F: MINNESOTA AND WISCONSON USAGE

Fiscal Year: 2024-2025

MINNESOTA: State Fiscal Year 2024 and State Fiscal Year 2025 Minnesota Usage

Procedure Code

SFY2024 SFY2025

V2020 21,795 22,222 V2025 931 1,041 V2100 3,140 3,115 V2101 312 320 V2102 86 94 V2103 10,497 10,930 V2104 2,612 2,760 V2105 513 600 V2106 68 65 V2107 1,677 1,623 V2108 647 673 V2109 218 208 V2110 23 25 V2111 403 409 V2112 246 251 V2113 62 58 V2114 124 135 V2115 0 1 V2121 2 5 V2200 1,135 1,204 V2201 62 74 V2202 8 20 V2203 4,705 4,943 V2204 657 667 V2205 84 101 V2206 16 11 V2207 501 499 V2208 129 164 V2209 26 24 V2210 7 6 V2211 121 120 V2212 49 48 V2213 14 12 V2214 17 24 V2219 38 40 V2220 13 26 V2221 9 14

Rev. 9.01.2021

V2300 54 45 V2301 4 0 V2302 1 0 V2303 258 266 V2304 39 44 V2305 1 2 V2306 0 1 V2307 29 22 V2308 4 9 V2311 7 10 V2312 3 3 V2314 1 0 V2320 2 2 V2410 16 2 V2710 3 2 V2715 647 617 V2718 2 2 V2744 305 313 V2745 40 38 V2755 4 2 V2762 1 2 V2782 174 164 V2783 1,201 1,234 V2784 18,456 19,316

WISCONSIN: State Fiscal Year 2024 and State Fiscal Year 2025 Wisconsin Usage

Procedure Code SFY24 SFY25

S0516

V2020

35,318

33,573

V2020RP

V2020U3

V2025

1,359

1,329

V2100

5,585

5,094

V2101

V2102

V2103

25,070

25,191

V2104

5,255

5,506

V2105

V2106

V2107

3,648

3,473

V2108

1,195

1,214

V2109

V2110

V2111

V2112

V2113

V2114

V2115

V2118

V2121

V2200

3,275

2,858

V2201

V2202

V2203

19,197

17,172

V2204

1,929

1,802

V2205

V2206

V2207

1,508

1,307

V2208

V2209

V2210

V2211

V2212

V2213

V2214

V2215

V2218

V2219

V2220

V2221

V2300

V2301

V2302

V2303

1,201

1,040

V2304

V2305

V2306

V2307

V2308

V2309

V2310

V2311

V2312

V2313

V2314

V2315

V2318

V2319

V2320

V2321

V2410

V2430

V2499

V2700

V2710

V2715

1,564

1,406

V2718

V2730

V2744

V2745 61 82

V2755 4 -

V2760 - -

V2762 4 4

V2770 - -

V2780 - -

V2781 90 70

V2782 50 36

V2783 372 386

V2784 19,740 19,636

V2799 - -

Attachment G: Third Party Vision Insurance Plans

PrimaryName Address1 Address2 City State Zip Count Enrollees

VISION SERVICE PLAN PO BOX 997100 SACRAMENTO CA 95899 4,605

EYEMED VISION CARE PO BOX 8504 MASON OH 45040 4,321

AVESIS INC VISION CLAIMS PO BOX 38300 PHOENIX AZ 85069 786

DAVIS VISION VISION CLAIMS PO BOX 1525 LATHAM NY 12110 724

BCBS NEW YORK VISION PO BOX 1525 LATHAM NY 12110 702

UNITED HEALTH VISION OPTIMHEALTH ATT CLAIMS PO BOX 30978 SALT LAKE CITY UT 84130 682

AMERITAS LIFE INS CO PO BOX 82520 LINCOLN NE 68501 671

BLUE CARD CLAIMS BCBS OF MINNESOTA PO BOX 64560 ST PAUL MN 55164 268

METLIFE VISION DAVIS VISION SUPERIOR V PO BOX 509 TROY NY 12181 213

SUPERIOR VISION METLIFE VISION PO BOX 509 TROY NY 12181 143

UNITED HEALTH CARE PO BOX 30555 SALT LAKE CITY UT 84130 141

AETNA TEXAS PO BOX 981106 EL PASO TX 79998 140

EYEMED VISION ATTN VISION CLAIMS PO BOX 8504 MASON OH 45040 135

UNUM VISION PO BOX 14389 BATON ROUGE LA 70898 121

VISION SERVICE PLAN PO BOX 385018 BIRMINGHAM AL 35238 111

VISION SERVICE PLAN PO BOX 49518 CINCINNATI OH 45249 95

DATAMARK/BCBS MINNESOTA PO BOX 982813 EL PASO TX 79998 93

BLUE VIEW VISION PO BOX 8504 MASON OH 45040 86

MET LIFE TEXAS PDP PLAN PO BOX 981282 EL PASO TX 79998 86

DAVIS VISION 175 E HOUSTON ST SAN ANTONIO TX 78205 84

VISION SERVICE PLAN 3333 QUALITY DR RANCHO

CORDOVA

CA 95670 83

HEALTH PARTNERS PO BOX 1309 MAILSTOP 21103R MINNEAPOLIS MN 55440 76

CIGNA TENNESSEE PO BOX 188061 CHATTANOOGA TN 37422 71

SUPERIOR VISION ATTN CLAIMS PROCESSING PO BOX 509 TROY NY 12181 70

PRINCIPAL FINANCIAL GRP PO BOX 10357 DES MOINES IA 50306 67

DELTA VISION CLAIMS C/O EYEMED VISION CARE PO BOX 8504 MASON OH 45040 65

FEP BLUEVISION PO BOX 1525 LATHAM NY 12110 61

UMR WAUSAU-UTAH PO BOX 30541 SALT LAKE CITY UT 84130 60

VISION SERVICES PROGRAM PO BOX 997100 SACRAMENTO CA 95899 55

GUARDIAN DENTAL GROUP DENTAL CLAIMS PO BOX 981572 EL PASO TX 79998 54

MEDICA PO BOX 30990 SALT LAKE CITY UT 84130 53

HUMANA HEALTH CARE PLAN PO BOX 14601 LEXINGTON KY 40512 51

SPECTERA VISION PLAN PO BOX 30978 SALT LAKE CITY UT 84130 48

GUARDIAN VISION PO BOX 981572 EL PASO TX 79998 47

HUMANA VISION PO BOX 14313 LEXINGTON KY 40512 47

AMERITAS PO BOX 82520 LINCOLN NE 68501 44

OXFORD UHC PO BOX 31394 SALT LAKE CITY UT 84131 44

NATIONAL VISION ADMIN PO BOX 2187 CLIFTON NJ 07015 38

UMR WALMART GROUP PO BOX 30541 SALT LAKE CITY UT 84130 32

MET LIFE VISION PO BOX 997565 SACRAMENTO CA 95899 30

GUARDIAN DENTAL & VISION PO BOX 981572 EL PASO TX 79998 29

CIGNA VISION PO BOX 385018 BIRMINGHAM AL 35238 25

MUTUAL OF OMAHA CLAIMS DEPARTMENT 3300 MUTUAL OF OMAHA

PLAZ

OMAHA NE 68175 24

SUPERIOR VISION SERVICES ATTN CLAIMS PROCESSING PO BOX 967 RANCHO

CORDOVA

CA 95741 23

DATAMARK/BCBS MINNESOTA FEDERAL EMPLOYEES PO BOX 982813 EL PASO TX 79998 21

CIGNA CALIFORNIA VISION DIVISION PO BOX 997561 SACREMENTO CA 95899 18

CIGNA VISION PO BOX 385018 BIRMINGHAM AL 35238 18

DELTA DENTAL MINNESOTA PO BOX 9120 FARMINGTON

HILLS

MI 48333 18

GUARDIAN PO BOX 8013 APPLETON WI 54913 18

WILSON-MCSHANE CORP. 3001 METRO DRIVE BLOOMINGTON MN 55425 18

ZENITH AMERICAN SOLUTIONS/MN LABORERS 2520 PILOT KNOB RD #325 ST PAUL MN 55120 18

EYE MED PO BOX 554 MILWAUKEE WI 53201 17

BCBS TEXAS PO BOX 660350 DALLAS TX 75266 16

WILSON-MCSHANE CORP OPERATING ENG LOCAL 49 3001 METRO DRIVE BLOOMINGTON MN 55425 16

BCBS OHIO/ANTHEM BCBS PO BOX 105187 ATLANTA GA 30348 15

DATAMARK/BCBS MINNESOTA MN ADVANTAGE HEALTH PLAN PO BOX 982813 EL PASO TX 79998 15

PREFERRED ONE ADMIN SVCS PO BOX 59212 MINNEAPOLIS MN 55459 15

MEDICA MAYO PLAN ATTN MAYO HEALTH EMPL PO BOX 211435 EAGAN MN 55121 14

VSP DIRECT 7400 GAYLORD PKWY FRISCO TX 75034 14

MET LIFE VISION 200 PARK AVE NYC E NY 10166 13

BCBS NORTH DAKOTA 4510 13TH AVE S.W. FARGO ND 58121 12

DELTA DENTAL WISCONSIN PO BOX 828 STEVENS POINT WI 54481 11

LINCOLN VISION CONNECT PO BOX 30978 SALT LAKE CITY UT 84130 11

SUN LIFE FINANCIAL PO BOX 2940 CLINTON IA 52733 11

HUMANA INSIGHT NETWORK PO BOX 3233 MILWAUKEE WI 53201 10

ATTACHMENT H: GOVERNMENTAL AGENCY LIST AND SCOPE OF WORK PROVIDED

Responder/Company Name:

Contact Name:

Address:

Email:

Phone Number:

Instructions: List below at least three (3) recent or current governmental agencies for which your company has provided an equivalent level of service including a brief description of the Scope of Work provided to the agencies.

1.

2.

3.

6. Business Information