Spec JC 2026 SELF-FUNDED MED _ PRESC DRUG EXCESS STOP LOSS COVERAGE.pdf

REQUEST FOR PROPOSALS

SELF-FUNDED MEDICAL AND PRESCRIPTION DRUG

EXCESS STOP LOSS COVERAGE

EFFECTIVE DATE-JANUARY 1, 2026

SUBMISSION DEADLINE:

THURSDAY, OCTOBER 16, 2025

AT 4:00 PM

ALL PROPOSALS SHALL BE ADDRESSED AND DELIVERED

TO THE DEDICATED LOCKBOX:

Raquel Tosado, Director, Purchasing Agent

City of Jersey City

Division of Purchasing

280 Grove Street, 1st Floor, Room 116

Jersey City, NJ 07302

Section I: Introduction……………………….…...…………………………………..……..…… 3

Jersey City Overview & Plan Summary …...……………………………………..….….. 3

Procurement Process………………………………………….………………………….. 3

Employee and Retiree Eligibility…………………………………………...………..……4

Contributions……………………………………………………………….………..……4

Current Excess Coverage Summary…..…………………………………….…………… 4

Section II: Bidding Conditions…..………………………………...…………………………..…5

Networks………………………………………………...……………………………….. 5

Submission of proposal……………………………………………………….……….. …6

Timeline……………………………………………………………………...……..……. 6

Proposal Format…………………………………………………………...…….………. .6

Inquiries & Correspondence…………………………………………………….……...…6

Payments to Vendor…………………………………………………………….…………7

Confidentiality……………………………………………………………….….……….. 7

Employee/Retiree Census…………………………………………………….…….….….8

Claims Data………………………………………………………………………………. 8

Section III: General Terms and Conditions………………………………………………...…… 7

City’s Right to Reject…………………………………………………………..……....… 7

Original/Authorized Signatures……………………………………………….…………. 8

Delivery of Proposals……………………………………………………………………...8

Affirmative Action Requirements……………………………………………...……….…8

Business Registration Certificate………………………………..………………………...9

Clarification of RFP…………………………………………………………………....… 9

Indemnification…………………………………………………………………..........…. 9

Insurance Requirements……...…………………………………………………………. 10

Termination……………………………………………………………………………

City of Jersey City Lobbyist Disclosure Ordinance……………………….…...…….10-11

Appendix A: Intent to Bid Form……………………………………………………….…..……12

Confidentiality Agreement…………………………………………………………………….…12

Signature Page……………………………………………………………….……………….….13

Appendix B: Medical Benefits Grid…………………………………………………………….14

Appendix C: Prescription Benefits Grid ………………………………………..…………..….16

Required Administrative Forms………………………………………….……………….…….17

City of Jersey City Request for Proposal

Section I: Introduction and General Information

Overview

Jersey City is the second largest City in New Jersey and has a population of approximately 300,000 residents. Jersey City self-insures its employee medical and prescription drug coverages. As such, the

City purchases excess loss coverage. The City’s current excess loss coverage expires on December

31, 2025. This Request for Proposals (RFP) provides extensive information about the City of Jersey

City and its self-insured medical and prescription drug plans. Licensed stop loss insurers and

Managing General Underwriters are invited to submit proposals for excess loss coverage in accordance with the specifications provided herein. Acrisure, LLC is the current Health Care Consultant for the

City of Jersey City and has been charged with the responsibility of reviewing responses to this RFP.

Plan Summary

There are approximately 2,530 active employees and approximately 2,433 retirees enrolled in the self-funded medical plan and approximately 3,843 active and early retirees enrolled in the self-funded prescription drug plans. In addition, there are approximately 2,034 enrolled in the EGWP Plan (age

65+ retirees). The self-insured medical plan is currently administered by Horizon Blue Cross and Blue

Shield of New Jersey provides ten (12) self-funded plan options: one (1) Traditional Plan, seven (7)

Direct Access Plans, two (2) Exclusive Provider Organization (EPO) plans, and one (1) Omnia Plan and (2) H.S.A. options. The only members in the Traditional Plan are retirees, and this plan is no longer available for enrollment. Virtually all of the current enrollment is in the Direct Access Plans, and benefits vary in each of the 7 plans depending on Collective Bargaining Agreements for each

Union. The City introduced the EPO, OMNIA and recently the H.S.A. plan options as a low cost plan option for employees and retirees, however enrollment is low. Based on a recent Collective Bargaining

Agreement with several unions, the City expects the OMNIA enrollment to increase slowly over the next several years. The stand-alone prescription coverage is administered through Express Scripts Inc.

for active employees and dependents along with early retirees and dependents. Standalone prescription drug coverage for Retirees over age 65 is provided through an Employer Group Waiver Plan (EGWP) program administered by Express Scripts, Inc. The City has recently Requested Proposals for TPA

Administration of the Medical plan for 2026 and has not yet completed the review of the Horizon

BCBSNJ renewal proposal or the Meritain Health/Aetna proposal. There were no other proposals received and the City expects to conclude the review of these options shortly. A final decision will be advertised as part of the Request for Proposal process for Stop Loss Insurance.

This RFP is requesting an Excess Loss contract to cover the entire population under a single risk pool contemplating the current plan designs for both medical and prescription drug coverage.

Plan design information for the self-funded Medical and Prescription drug plans is enclosed in this package and the attached Appendix B and C.

Procurement Process

This contract will be awarded as an Extraordinary Unspecifiable Services (“EUS”) agreement for insurance services pursuant to N.J.S.A. 40A:11-5(1)(a)(ii).

The City Council will vote to approve a resolution awarding the contract to the Consultant for a sum not to exceed a specified amount and for a term of one (1) year. The decision to select a Consultant shall be based upon pricing, ability to perform services, pay claims in a timely manner and general reputation in the field.

Employee and Retiree Eligibility

Employees who work at least 26 hours per week are eligible for benefits. Medical coverage begins sixty

(60) days from date of hire. Children are covered until the end of the month during which they reach age twenty-six (26). Any changes in coverage due to a qualifying event must be done within sixty (60) days of the event.

The City will pay the cost of health coverage, which includes health insurance and the prescription drug plan, for all retirees and their eligible dependents so long as the retiree has retired from the

City after twenty-five (25) or more years of service credit in the Police and Fire Retirement System.

The City and the Union may agree to permit a retiree who does not meet the above requirements to participate in the City’s health insurance and prescription drug plan at his/her own cost.

In most cases, retirees and all Medicare-eligible persons are required to enroll in both Medicare

Parts A&B and will be responsible for any premiums required due by Medicare. Both plans offered by the City will provide coordination of benefits with Medicare being the primary payor.

There may be a few instances in which the individual has not enrolled in Medicare.

Contributions

Current employee contributions for the medical plans are as required by State law under Chapter

78, as it applies to New Jersey Municipal Employees.

Medical and Rx Excess Stop Loss: Please quote specific deductible options of $300,000, $350,000 and $400,000.

Current Excess Coverage Summary

Specific Coverage Summary for Calendar Year 2023 Individual Specific Deductible $300,000

Aggregating Specific Deductible $400,000

Specific Contract Basis 24/12

Specific Contract Includes Medical & Rx

Specific Annual Maximum Unlimited

Specific Composite Monthly Rate: PMPM $84.97

Average Number of Lives 4,963

Coverage Includes Specific Advance Yes

Aggregate Coverage Summary

Aggregate Monthly Composite Factor $3,099.72

Aggregate Contract Basis 24/12

Aggregate Contract Includes Medical & Rx

Maximum Aggregate Benefit $1,000,000

Aggregate Composite Monthly Rate $1.00

Aggregate Corridor 125%

Please Note: Most, but not all, Retirees who are Medicare eligible are Medicare primary.

Section II: Bidding Conditions

This section provides general bidding conditions and instructions for quoting on the current coverage and the alternatives described herein. All bidders must satisfy and describe their ability to meet these requirements. If you cannot meet any of the following provisions, please present alternatives that effectively meet the City’s concerns or objectives.

The successful bidder may be required to have completed the attached forms prior to the time of contract award. If submitting a proposal, make sure your firm is able to properly complete these forms and requirements.

Networks

Jersey City is currently using the following networks for its medical plans:

Self-Insured Medical Plans: Horizon Blue Cross and Blue Shield Networks

Multiplan Network (out of Network)

Self-Insured Retail Rx: Express Scripts Network Participating Pharmacies

Mail Order Rx: Express Scripts Mail Order Pharmacy

1. Assume a January 1, 2026, effective date for the start of services.

2. Your proposal must assume coverage for the plan designs outlined in this Request for

Proposals (RFP). If you are unable to provide coverage for the plan designs outlined in this

RFP, any deviations in your proposal must be noted.

3. Actively at work requirements must be waived.

4. Policy must cover both Active and Retired employees. By and large, Medicare will be primary for the vast majority of the 65+ retirees; however there may be a minimum number of retirees who do not have Medicare. As such, Medicare would not be primary.

5. Supply of claim forms

6. Data required for compliance with governmental reporting requirements.

7. Proposals and contracts should include no commissions.

8. Stop loss quotes must be on a 24/12 or paid contract basis for both specific and aggregate coverages.

9. Specific Deductible Options of $300,000, $350,000 and $400,000 should be quoted.

10. The specific stop loss must include advanced/immediate funding.

11. The specific coverage must include at an unlimited lifetime maximum.

12. Horizon Blue Cross and Express Scripts, Inc. must be an approved plan administrator.

13. The current specific and aggregate coverage includes medical and prescription drug. The aggregate coverage should be based on a 125% corridor.

14. The plan information, census data and specifications are confidential and are to be used for bidding purposes only.

15. Stop Loss Insurer must provide full high claim administration and provide full claim processing for all applicable claims, accessing required information from the medical and

Rx plan administrator.

Submission of Proposal

Proposals may be sent by U.S. certified mail return receipt requested or may be sent by private courier service to a dedicated lockbox located at:

Raquel Tosado, Director, QPA

City of Jersey City

Division of Purchasing

280 Grove Street, 1st floor, Room 116

Jersey City, NJ 07302

Proposals forwarded by facsimile or e-mail will not be accepted. Proposals sent by mail or courier service must be received by the Purchasing Agent no later than 4:00 P.M. on the last City business day before the day of the bid due date or no later than 4:00 P.M. on the due date. Mail/Courier services need to be instructed to hand deliver proposals to the dedicated lockbox. Office hours Monday through Friday from 9:00 am to 4:00pm. The City shall not be responsible for the loss, non-delivery or physical condition of proposals sent by mail or courier service.

Proposals must be submitted individually in a sealed envelope addressed to the Purchasing

Agent. Proposals must comply with specifications. Any proposal received after the date and time specified will be returned, unopened, to the bidder.

The successful bidder shall be required to have completed the attached forms prior to the time of contract award. If submitting a proposal, make sure your firm is able to properly complete these forms and requirements.

A Timeline of Events Are:

Responses Due by 4:00 P.M. October 16, 2025

Council Meeting / Award of Contract November 12, 2025

Proposal Format

Proposals must address all information requested in this RFP. Proposals which in the judgment of the City fail to meet the requirements of the RFP or which are in any way conditional, incomplete, obscure, contain additions or deletions from requested information, or contain errors may be rejected.

Inquiries, Correspondence and Addendums

During the period provided for the preparation of responses to the RFP, the City may issue addenda, amendments or answers to written inquiries. Those addenda will be noticed by the City and will constitute a part of the RFP. Each Respondent is required to acknowledge receipt of all addenda by executing and submitting with its Proposal the Acknowledgement of Receipt of

Addenda form. If the form is not submitted with the proposal, the Proposal will be rejected. All responses to the RFP shall be prepared with full consideration of the addenda issued prior to the

Proposal submission date.

ALL COMMUNICATIONS, QUESTIONS, AND CLARIFICATIONS CONCERNING THIS

RFP OR THE RFP PROCESS SHALL BE CONDUCTED THROUGH THE CITY’S ONLINE

PURCHASING PORTAL AT WWW.BIDNETDIRECT.COM. Responses to all questions will be forwarded as addenda to all prospective Respondents who have provided accurate and current contact information.

Responses will also be made available on the BidnetDirect.com portal.

Payment to Consultant

The City will make monthly payments to the Consultant via partial payment vouchers which will be supplied to the Consultant. Payment will be based on the monthly rates per enrollee that

Consultant submitted in response to the RFP and the number of enrollees each month. Based on the information in the Excess Loss Coverage Summary on page 4, the Consultant will also supply the City with an estimated total annual cost for providing these services to the City.

Confidentiality

No data or details of this RFP are to be shared with outside parties, for any purposes other than responding to the RFP without the prior written approval of Jersey City. The attached Statement of Confidentiality and Signature Page are required to be returned with your proposal. In consideration of disclosure to Respondent of the this RFP request and additional evaluation material, recipient agrees that it will abide by such determination that the evaluation material is confidential, making all necessary and appropriate efforts to safeguard the evaluation material and http://www.bidnetdirect.com./ keeping such evaluation material confidential and that, without the prior written consent of the

City of Jersey City, the evaluation material will not be disclosed by Respondent and will not be used by Respondent other than in connection with its evaluation of and consideration of the project and will not be used in any way detrimental to the City of Jersey City or its employees. Moreover, Respondent agrees to transmit the evaluation material only to such of its representatives who need to know the evaluation material for the sole propose of assisting Respondent in evaluating the evaluation material and considering the project who are informed of this Agreement and who agree to be bound by the terms hereof as if a party here to.

Employee/Retiree Census

An active employee census file and retiree census file may be provided upon request to

Respondents who intend on providing a quotation. Those requests should be directed to the

Purchasing Agent through www.Bidnetdirect.com, who will provide them to you immediately.

Claims Data

Claims data for the current self-funded medical and Rx plans administered by Horizon and Express

Scripts are available upon request to Respondents who intend on providing a quotation. Those requests should be directed to the Purchasing Agent through www.bidnetdirect.com, who will provide them to you immediately.

Section III: General Terms and Conditions

The following are general terms and conditions which may or may not be explained elsewhere in this RFP.

City’s right to reject

The City reserves the right to reject any or all proposals, if necessary or to waive any informalities in the proposals, and, unless otherwise specified by the Respondent, to accept any item, items or services in the Proposal should it be deemed in the best interest of the City.

Original/Authorized Signatures

Each proposal and all required forms must be signed in ink by a person authorized to do so.

The Consultant will be required to have completed the attached forms prior to the time of contract award. If submitting a proposal, make sure your firm is able to properly complete these forms and requirements.

http://www.bidnetdirect.com/ http://www.bidnetdirect.com/

Affirmative Action requirements

Respondents are required to comply with the provisions of N.J.S.A. 10:5-31 and N.J.A.C. 17:27 et seq. No Contractor may be issued a contract unless it complies with these affirmative action provisions.

The Mandatory Equal Employment Opportunity/Affirmative Action Language for Goods, Professional Services and General Service Contracts, Exhibit A summarizes the full required regulatory text.

Goods and Services (including professional services) consultants/contractors shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

a. A photocopy of a valid letter that the contractor is operating under an existing Federally approved or sanctioned affirmative action program (good for one year from the date of the letter); or

b. A photocopy of a Certificate of Employee Information Report approval, issued in accordance with N.J.A.C. 17:24-4; or

c. A photocopy of an Employee Information Report (Form AA302) provided by the Division and distributed to the public agency to be completed by the contractor, in accordance with

N.J.A.C. 17:27-4.

For information on AA/EEO requirements and forms ONLY, please contact:

Jeana F. Abuan, EEO/AA/PACO Officer/Director

Department of Administration, Office of Tax Abatement & Compliance

280 Grove Street, Lower Level, Room 109-B Lower Level

Jersey City, NJ 07302

Tel. 201-547- 4538

E-mail Address: abuanj@jcnj.org

Business Registration Certificate

P.L. 2004 c. 57 (Chapter 57) amends and supplements the business registration provisions of

N.J.S.A. 52:32-44 which impose certain requirements upon a business competing for or entering into a contract with a local contracting agency whose contracting activities are subject to the requirements of the Local Public Contracts Law (N.J.S.A. 40A:11-1 et seq).

Consultants are required to comply with the requirements of P.L. 2004, c.57 (Chapter 57) which include submitting a copy of their Business Registration Certificate (BRC), issued by the NJ

Department of the Treasury.

Clarification of RFP

Should any difference arise as to the meaning or intent of this RFP, the City’s Business

Administrator’s decision shall be final and conclusive.

mailto:abuanj@jcnj.org

Indemnification

The Consultant, awarded the contract agrees to protect, defend, indemnify and save harmless the

City against damage for payment for the use of any patented material, process, article or device that may enter into the manufacture, construction or form a part of the work covered by either order or contract, further agrees to indemnify and save harmless the City from suits or actions of every nature and description brought against it for, or on account of, any injuries or damaged received or sustained by any party or parties, by or from, any of the acts of the Consultant its servants or agents.

Insurance requirements

The Consultant shall maintain sufficient insurance to protect against all claims under Worker’s

Compensation, General and Automobile Liability and shall be subject to City Risk Manager’s approval of adequacy of protection. Certificates of such insurance shall be provided the City when required. Insurance requirements are as follows:

Commercial General Liability in the amount of $2,000,000 per occurrence and in the aggregate; including Products and Completed Operations coverage.

Worker’s Compensation with NJ statutory limits and Employer’s Liability in the amount of

$1,000,000.

Professional Liability in the amount of $2,000,000 per occurrence and in the aggregate. Cyber

Liability in the amount of $2,000,000 each incident and in the aggregate.

Certificate of Insurance

Before commencing the work, the Consultant shall furnish the City with a Certificate of

Insurance (Certificate) verifying evidence of such insurance. Where applicable all Certificates shall name “City of Jersey City, its officers and employees as an additional insured on a primary, noncontributory basis”. All Certificates shall bear said City Project Name and Number if applicable.

Coverage Effective Period

The insurance policies required shall be kept in force for a period specified below:

• General Liability, Automobile Liability, Cyber Liability and Workers’

Compensation policies shall be kept in force until submission of the Contactor’s final invoice.

• Professional Liability coverage must be effective retroactive to the earlier of the date of the Agreement or the date of a Notice-to-Proceed and policy shall be kept in force until at least three (3) year after completion of this Contract / Project or, if said coverage is not commercially available for such term, then for such term as is commercially available.

Termination

Should a dispute arise, and if, after a good faith effort at resolution, the dispute is not resolved, either party may terminate the contract by providing 30 days’ written notice to the other party.

Regardless, the City reserves the right to cancel the contract at its convenience by providing 30 days’ written notice to the Consultant.

City of Jersey City Lobbyist Disclosure Ordinance

The contract will be awarded in accordance with the provisions of the City’s Disclosure of

Lobbyist Representative Status Ordinance §3-9.1 et seq. adopted on June 12, 2002. The

Successful Consultant will be required to certify that the Successful Consultant either did not retain the services of a lobbyist to lobby on behalf of the Successful Consultant for the award of this contract, or if a lobbyist was retained by the Successful Consultant for such purposes, the

Successful Consultant’s lobbyist, prior to commencing his/her lobbying activities, shall have filed a notice of lobbyist representative status form with the City Clerk. The Successful

Consultant whose lobbyist failed to comply with the provisions of Ordinance §3-9.1 et seq, following notice and an opportunity to be heard, shall be disqualified from entering into contracts with the City for a period of two (2) years for each violation.

Appendix A

City of Jersey City RFP Intent to Bid Response Form

Return This Form with Your Proposal

PROJECT: Self-Funded Medical and Prescription Drug Excess Loss Coverage

RESPONDENT: ________________________________________________________________________

SUBMIT THIS WITH YOUR PROPOSAL

We have reviewed the request for proposal for the Jersey City Self-Funded Medical and

Prescription Drug Excess Loss Coverage.

We intend to meet the specifications outlined and are submitting a proposal for the Jersey City Self-Funded Medical and Prescription Drug

Excess Loss Coverage

❑ Yes ❑ No

Deviations are detailed in the section of our proposal titled: “Deviations to Bid Specifications”

❑ Yes ❑ No

Confidentiality Agreement:

In consideration of disclosure to Recipient of the evaluation material, recipient agrees that it will abide by such determination that the evaluation material is confidential, making all necessary and appropriate efforts to safeguard the evaluation material and keeping such evaluation material confidential and that, without the prior written consent of the City of Jersey City, the evaluation material will not be disclosed by Recipient and will not be used by Recipient other than in connection with its evaluation of and consideration of the project and will not be used in any way detrimental to the City of Jersey City or its employees. Moreover, Recipient agrees to transmit the evaluation material only to such of its representatives who need to know the evaluation material for the sole propose of assisting Recipient in evaluating the evaluation material and considering the project who are informed of this Agreement and who agree to be bound by the terms hereof as if a party here to.

All costs associated with completing and preparing the project response will be borne by you and not City of Jersey City.

We comply with all of the above conditions, except as noted on the Section of our proposal titled

“Deviations to Bid Specifications”.

I certify that the responses to the questions contained in this RFP are accurate.

SIGNATURE PAGE

RETURN THIS FORM WITH YOUR PROPOSAL

Name / Title

On behalf of:

Company Name

Company Address

Date:

Phone Number:

E-mail Address:

NOTE: Your typed name and date above will be considered a valid signature for this RFP.

Appendix B

Medical Benefits Grid

See Attached Apendix B

See Attached Apendix C

Appendix C

Prescription Benefits Grid

Full Summary of Benefits will be provided upon request from parties intending to provide a quotation.

Full Summary of Benefits will be provided upon request from parties intending to provide a quotation.

REQUIRED ADMINISTRATIVE FORMS

PROJECT: SELF-FUNDED MEDICAL AND PRESCRIPTION DRUG EXCESS

STOP LOSS COVERAGE

RESPONDENT: __________________________________________________________

Please place the checklist and the required forms at the front of your proposal.

RESPONDENT=S CHECKLIST

Item

Respondent

Initials

Purchasing

Review

*Acknowledgment of Receipt of Addenda

*Statement of Ownership Disclosure

Mandatory Affirmative Action Language (Exhibit A)

Non-Collusion Affidavit (Notarized)

Americans with Disabilities Act (Appendix A)

With Proposal or after notification of award, but prior to signing a contract, submit photocopy of one of the following three documents:

1. A valid letter that the contractor is operating under an existing Federally approved or sanctioned affirmative action program (good for one year from the date of the letter); or

2. Unexpired Certificate of Employee Information

Report; or

3. Employee Information Report (Form AA302) if first time doing business with Jersey City.

Supplier Diversity Questionnaire

Business Registration Certificate

Disclosure of Investment Activities in Iran

Original signature(s) on all required forms

*A Proposer’s failure to include these forms with its proposal will result in the rejection of the proposal.

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal.

Name of Organization:_________________________________________________________________

Organization Address:_________________________________________________________________

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

Partnership Limited Partnership Limited Liability Partnership (LLP)

Other (be specific): ______________________________________________

Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE

THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS

OR LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed.

Stockholder/Partner/Member and Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the CITY OF JERSEY CITY is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with the CITY OF JERSEY CITY to notify the CITY OF JERSEY CITY in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, CITY OF JERSEY CITY to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print): Title:

Signature: Date:

THE CITY OF JERSEY CITY IS AN AFFIRMATIVE ACTION & EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH ALL

LOCAL, STATE AND FEDERAL LAWS AND REGULATIONS IN EMPLOYMENT AND CONTRACTING.

SUPPLIER DIVERSITY BIDDER QUESTIONNAIRE

The City of Jersey City is committed to ensuring that its utilization of vendors reflects the diversity of its community. Please complete this form to assist us with monitoring our supplier diversity performance.

Business Name: ________________________________________________________________

Address: ________________________________________________________________

Phone: ________________________________________________________________

Email: ________________________________________________________________

Contact Name: ________________________________________________________________

Please indicate if your business qualifies as any of the following: (See definitions for clarification)

� Minority Owned

� Woman Owned

� Veteran Owned

� Disability Owned

� Lesbian, Gay, Bisexual, Transgender Owned

� None

Please indicate if your business is currently certified by an authorized certifying body as any of the following:

� Minority Business Enterprise

� Woman Business Enterprise

� Veteran Business Enterprise

� Disability Owned Business Enterprise

� Lesbian, Gay, Bisexual, Transgender Business Enterprise

� Disadvantaged Business Enterprise

� Small Business Enterprise

� None

THE CITY OF JERSEY CITY IS AN AFFIRMATIVE ACTION & EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH ALL

LOCAL, STATE AND FEDERAL LAWS AND REGULATIONS IN EMPLOYMENT AND CONTRACTING.

SUPPLIER DIVERSITY DEFINITIONS

Minority Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by persons who are African American, Hispanic, Asian American, American Indian or Alaskan Native, defined as follows:

African American: a person having origins in any of the black racial groups of Africa.

Hispanic: a person of Mexican, Puerto Rican, Central or South American or other non-European Spanish culture or origin regardless of race.

Asian: a person having origins in any of the original peoples of the Far East, South East Asia, Indian subcontinent, Hawaii or the Pacific Islands.

American Indian or Alaskan Native: a person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

Woman Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a woman or women.

Veteran Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a person or persons who are veterans.

"Veteran" means any citizen and resident of this State now or hereafter honorably discharged or released under honorable circumstances who served in any branch of the Armed Forces of the United States or a Reserve component thereof for at least 90 days and shall include disabled veterans.

Disability Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a person or persons with a disability.

Lesbian, Gay, Bisexual, Transgender Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by an LGBT person or persons.

The Certification form requires the insertion of contracting unit identification information which should be filled in (in italics on the form) prior to its use.

STANDARD BID DOCUMENT REFERENCE

Name of Form DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN

Statutory Reference

N.J.S.A. 52:32-55 et seq.

N.J.S.A. 40A:11-2.1

N.J.S.A. 18A:18A-49.4

Applicability

Y/N Mandatory Optional N/A

LPCL Y

Goods and Services

X

PSCL Y Construction

X

Instructions Reference

Description P.L. 2012, c.25 prohibits the awarding of State and local public contracts for goods and services with persons or entities engaging in certain investment activities in energy or finance sectors of Iran. Prior to contract award, vendors and contractors must certify that neither they nor any parent entity, subsidiary, or affiliate is listed on the New Jersey Department of the Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c.

25 ("Chapter 25 List").

Disclosure of Investment Activities in Iran

Person or Entity

Part 1: Certification

COMPLETE PART 1 BY CHECKING EITHER BOX.

Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate is identified on the

State Department of Treasury's Chapter 25 list as a person or entity engaging in investment activities in Iran.

The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.

The Chapter 25 list must be reviewed prior to completing the below certification. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may provided by law, rule or contract, including but not limited to imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.

I certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J.

Department of the Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip

Part 2 and sign and complete the Certification below.

OR

I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s

Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below.

http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf

Part 2: Additional Information

PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN.

You must provide a detailed, accurate and precise description of the activities of the person or entity, or a parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below and, if more space is needed, on additional sheets provided by you.

Part 3: Certification of True and Complete Information

I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments there to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above-referenced person or entity.

I acknowledge that the City of Jersey City is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the City of Jersey City to notify the City of Jersey City in writing of any changes to the answers of information contained herein.

I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the City of Jersey

City and that the City of Jersey City at its option may declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print)

Title

Signature Date