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INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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1. INTENT A. Collier County Sheriff’s Office [CCSO] hereby solicits quotations from qualified Contractors for the provision

of Medical Audit and Compliance Consulting Services to monitor our contract provider of Inmate Health Care Services.

B. The objective is to provide a fully responsive contract for Medical Audit and Compliance Consulting Services between Collier County Sheriff’s Office (CCSO) and a qualified Medical Audit and Compliance Consulting firm.

2. BACKGROUND

CCSO’s Correction’s Division consists of two jail centers, Naples Jail Center (NJC) and the Immokalee Jail Center (IJC). Naples Jail Center is the main facility for medical administration. Currently, the inmate Average Daily Population (ADP) of both jail centers is 800.

3. CONTRACTOR QUALIFICATIONS A. Physically located within the boundaries of and licensed to provide consulting services in the State of Florida

and must agree to the following: 1) A minimum of three years’ experience relevant to the services stated in this RFQ.

2) Shall include organization’s relevant project experience and company background information to

include the date proposing company became organized to provide medical audit and compliance consulting services.

3) Shall submit professional qualification resumes of the key employees that will be assigned to providing services for the medical audit and compliance consulting services.

4) Shall submit an action plan for immediate contract start-up. Action plan must provide a time-line and the

events that will transpire in order for immediate contract start on October 1, 2015.

5) Shall provide three references, one being governmental, where similar services are/were being performed. Must include current information of the organization’s contact names, physical address, telephone number, and email addresses.

6) Experience and familiarity with National Commission on Correctional Health Care (NCCHC) Accreditation Standards, Florida Model Jail Standards (FMJS) and Florida Corrections Accreditation Commission (FCAC).

7) If Respondent is an organization, it must maintain a drug-free workplace policy and said policy must

include pre-employment and random drug screening of all employees and shall certify at the time of submission of their proposal that such a program is in place and functioning. The Sheriff’s Office reserves the right to periodically request during the term of the contract, proof that the drug-free workplace is being conscientiously applied.

8) If the Respondent is an individual, he/she must be prepared to undergo a drug screen urinalysis prior to

issuance of a contract, and further, he/she must agree to be randomly tested once during each term of the contract, at a day and time selected by CCSO.

9) Contractor and their personnel and sub-contractors that require access to the correctional facilities will be mandated to undergo background checks through Jail Administration. Upon CCSO approval for facility access, CCSO will issue a Contractor ID card, which must be displayed at all times in or around the facility, and a mandated Correctional Officer escort will be provided.

10) Respondent must not employ unauthorized aliens in accordance with the provisions of Section 274A(e) of the Immigration and Nationality Act (8 U.S.C. 1324a).

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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11) In accordance with the provisions of Title VII of the 1968 Civil Rights Act as amended by the Equal Employment Opportunity Act of 1972 and Executive Order 11914, the Respondent in its employment practices will not discriminate on the basis of race, color, sex, religion, age, national origin or disability.

12) In accordance with Section 287.133(3)(a), Florida Statutes, prospective bidders must complete the attached Sworn Statement Pursuant to Section 287.133(3)(a), Florida Statutes, On Public Entity Crimes concerning convictions of the proposer for public entity crimes and return it with their proposal.

4. SCOPE OF SERVICE REQUIREMENTS A. Successful Contractor shall be expected to meet the following specifications and requirements. The listing

below is intended to be a guideline and should not be considered all-inclusive. Consulting services shall be focused on auditing the records of the Inmate Health Care Service Agreement of the contracting organization that provides medical services to inmates in CCSO’s correctional facilities.

B. Successful Contractor shall provide comprehensive services that are legally defensive and which meet all

Federal, State and local laws, statutes and ordinances governing such services. C. Medical Audit and Compliance Consulting Services shall include, but not limited to, the following services to

meet the objective of this RFQ:

1. Contractor shall ensure that their visits on-site to CCSO will ensure strict and proper compliance with the terms and conditions of the Inmate Health Care Services Agreement.

2. Contractor audits shall be performed on a quarterly basis during the months of November 2015, February

2016, May 2016, and July 2016, or on an as needed basis.

a. Services shall be performed on-site.

b. Each visit will comprise of one (1) or (2) consecutive calendar days.

c. The audit will ensure that strict and proper compliance to all conditions of the Inmate Health Care Services Agreement are being consciously applied by the inmate healthcare contractor.

3. Contractor agrees to perform the following services and all other services necessary to meet the objective of

this quote. If required, Contractor shall provide written analysis, including all supporting documentation and recommendations for corrective action.

a. Contractor shall conduct an on-site audit to ensure proper compliance of all expenses and service

fees.

b. Contractor shall confirm that payment credits are being issued and that accurate processing and accounting is being conducted by the health care services provider of inmate per diem and shall correct all inaccurate accounts.

c. Contractor shall ensure on-site reviews and compliance checks of the efficiency of operations and

performance, staffing, medical services, monitoring, financial audits, credit check, and the assurance of all payments.

4. Contractor auditing of the health services agreement includes, but not limited to, the following:

a. Contractual staffing and personnel requirements are being met, including the calculation of any

penalties resulting from staffing shortages. b. Contractor shall confirm that all staffing positions are manned by properly certified individuals as

required by the Inmate Health Care Services Agreement.

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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c. Validate and ensure that education and training, NCCHC Accreditation, psychological and psychiatric services requirements and services are being provided and met.

d. Contractor shall identify deficiencies that may result in penalties being due to CCSO through the failure of the inmate healthcare contractor to meet any of the listed standards.

e. In conducting audits Contractor shall look to identify efficiencies and best practices that seek to

improve inmate medical services and / or reduce the cost of such services and make recommendations for any identified areas of improvement to the Chief of Corrections.

f. Contractor shall be responsible for determining the amount of penalty due as that will be

determined collectively by the CCSO Finance Department and the inmate healthcare contractor.

g. Review working agreements with outside hospitals and healthcare providers that provide CCSO with a reasonable discount for services provided to inmates are in-place, being utilized, and audited to ensure billing at the proper rates.

h. Ensure that all off-site procedures provided by the inmate healthcare contractor are directed towards a serious medical need such that if not provided would in the opinion of the Medical Director cause the inmate’s health to deteriorate or cause definite harm to the inmate’s well-being.

i. Ensure all contractual staffing and personnel requirements are being met, including the calculation

of any deficiencies by staff category (i.e. RN, LPN, CNA, etc.) resulting from staffing shortages during the quarter and ensuring all positions are staffed at all times by properly certified individuals. Current contractual staffing requirements for the contractor are 31.15 FTE.

j. Ensure all education and training requirements are being met.

k. Ensure all required medical services (including fourteen day medical history and physical follow- ups) and treatment are provided to inmates within specified timeframes.

l. Ensure that all inmate records and charts are being accurately maintained and changes are

processed in a timely manner.

m. Ensure that the doctor and nursing staff are conducting sick call properly and in a timely manner.

n. Ensure that medications are being provided and distributed within the time limits prescribed by industry best practices and the Inmate Healthcare Services Agreement.

o. Ensure that dental and x-ray services are being satisfactorily provided to all inmates as necessary.

p. Ensure the Quality Assurance Program is on-going.

q. During each visit the Contractor will attend the Quarterly Medical Audit Committee (MAC) meeting and review the results of their audit with the Correctional Facility’s command staff, representatives of the inmate healthcare contractor and other associated CCSO members.

r. The Contractor will, within fourteen (14) calendar days of the on-site visit, provide a written report

to CCSO noting the results of the audit together with any recommendations for improving any areas that were found to be lacking during the visit. s. The Report is to be sent to the Chief of Corrections located at the Naples Jail Center with copies to the Health Services Administrator at the Naples Jail Center and the CCSO Finance Director located in the CCSO Headquarters Building.

t. In accordance with the HIPAA Privacy Rule, the Contractor will be required to enter into a Business

Associate Agreement with CCSO with respect to the disclosure of certain personal inmate health information.

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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u. Additional Services and Projects: From time to time, CCSO may request the Contractor to perform certain specific ad hoc projects on an as needed basis. Such projects can be undertaken with the mutual agreement of CCSO and the Contractor submits a work plan and a “not to exceed” budget are in writing by the Contractor and approved by CCSO.

v. The Contractor is not responsible for obtaining or negotiating any service provider agreements for the inmate healthcare contractor, only for ensuring that they are in-place and being used when necessary.

5. SUBMISSION FORMAT In responding to this Request for Quotation, the Respondent shall submit the following documents to be responsive to this request: A. Response to Contractor’s Qualifications B. Response to Scope of Services (SOS) C. Attachment A – Quotation Submission Authorization D. Attachment B – Price Proposal E. Attachment C – Contractor’s Exceptions F. Attachment D – Insurance Questionnaire G. Attachment E – Drug-free Workplace H. Attachment F – Unauthorized Aliens Statement I. Attachment G – Equal Rights Act Statement J. Attachment H - References K. Attachment I – Public Entity Crime Form

6. SUBMISSION ADDRESS Collier County Sheriff’s Office RFQ #2015.003 Medical Audit and Compliance Consultant Services Attn: Melissa Pearson, Purchasing Department 2885 County Barn Road Naples, FL 34112 7. SUBMISSION DEADLINE Quotations must be received at the address above no later than Monday, August 17, 2015 by 5:00 P.M. EDT.

8. INQUIRIES Questions concerning this Request for Quotations may be submitted to Melissa Pearson via email at melissa.pearson@colliersheriff.org. No oral communications, all answers to the written questions submitted by Respondents concerning the RFQ will be provided in the form of an addendum located on the CCSO website, colliersheriff.org, link: http://www2.colliersheriff.org/aboutus/purchasing/rfp1.asp.

9. EVALUATION This is an informal Request for Quotation and representatives of CCSO will evaluate the responses and determine the most qualified quotation meeting CCSO requirements. CCSO reserves the option to enter into discussions, interviews with the Respondent(s) considered most likely to meet the requirements for the purpose of negotiations on pricing and/or other portions of the quotations, if considered to be in the best interest of CCSO.

The evaluation criteria are listed below in relative order of importance.

1) Response to Scope of Services and Contractor’s Qualifications: Respondent’s ability to meet the requirements of the Scope of Services. The response level of detail, accuracy, and completeness in addressing all the items requested in this RFQ. Respondents shall demonstrate they fully understand the Scope of Services. Award points: 65%

2) Price: Price is a significant factor in considering the award placement; however, it is not the only factor. The award will not be based on price alone. Award points: 35%

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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GENERAL TERMS AND CONDITIONS 

A. DEFINITIONS For the purpose of this document only, the following terms apply:

1) Request for Quotation (RFQ). An informal solicitation process issued by a procurement office requesting quotes for goods and/or services. Various factors are evaluated for best value with price not being the primary evaluation factor.

2) CCSO means the Collier County Sheriff's Office, its correctional facilities, its divisions, substations, agencies,

officials, officers and employees. 3) Respondent means vendor, and its officers, agents, representatives, and employees. 4) Contractor means vendor awarded the contract.

B. CONTRACT TERM 1) The contract shall be for one year, and it shall commence on October 1, 2015 at 00.01 hours, EDT and it shall terminate on September 30, 2016 at 24:00 hours, EDT. 2) Contract funding is dependent upon appropriation of funds by the Collier County Government, Board of County Commissioners for the fiscal year (FY) October 1, 2015 – September 30, 2016; and each fiscal year thereafter for which the contract remains effective.

3) The RFQ’s terms and conditions and the contractor’s proposal response shall be part of the contract.

4) The contract shall be reviewed throughout its entire term, and CCSO shall deliberate contract cancellation upon discovery that the contractor is in violation of any agreement part including the inability by the contractor to provide the products, support, and/or service offered in their proposal response. C. CONTRACT RENEWAL 1) Within 30 days of contract term expiration, CCSO shall notify Contractor and upon mutual agreement, the contract may be renewed for two additional one-year extensions based upon negotiations of service delivery and costs. 2) Contractual provisions or services changes to be furnished under the contract shall be in writing, and the Sheriff, or designee, and the agent of the contractor must approve them. If a decision shall be made to increase the scope of the contract, the Sheriff, or designee, and the Contractor will mutually agree, in writing, to an adjusted contract price.

D. CONTRACT OWNERSHIP 1) In the event the agreement is terminated prior to its expiration, CCSO shall have sole ownership rights of all documentation that was designed, developed, and/or utilized in respects to this contract with the exception of proprietary or commercial software rights. It shall become exclusive property of CCSO. 2) All data to include electronic documents, technical data, materials that were originated and developed specifically for CCSO that were performed in accordance with the contract to include reports, surveys, charts, diagrams, literature, brochures, mailings, audio/video recordings, pictures, drawings, analysis, notes, memoranda, written procedures which are services of CCSO contract to include electronic documents shall remain the sole property of CCSO, and they shall be delivered to CCSO within 30 calendar days’ notice of contract termination.

3) Contractor shall be prohibited from selling products or deliverables produced under said contract awarded without explicit consent from CCSO.

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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E. CONTRACT TERMINATION 1) Unless otherwise mutually agreed by both parties, the awarded contract shall be terminated on September 30, 2016 at 24:00 hours, EDT. 2) Termination for Cause: The Collier County Sheriff's Office may terminate the awarded contract at any time that the Contractor fails to carry out its provisions or to make substantial progress under the terms specified in the contract.

a. The Collier County Sheriff's Office shall provide the Contractor with 30 business days’ notice of conditions endangering performance. If after such notice the Contractor fails to remedy the condition contained in the notice, the Collier County Sheriff's Office shall issue an order to stop work immediately.

b. The Collier County Sheriff's Office shall be obligated to reimburse the Contractor only for those services rendered prior to the date of notice of termination, less any liquidation damages that may be assessed for non-performance.

3) Termination by Mutual Agreement: With the mutual agreement of both parties upon receipt and acceptance of not less than 30 business days written notice, the awarded contract may be terminated on an agreed date prior to the end of the contract period without penalty to either party.

4) Termination for Special Situations: Either party may terminate the awarded contract immediately following 30 business days written notification to the other documenting the occurrence of any of the following:

a. In the event there is a change in the Office of Sheriff due to an election, resignation or death and the Sheriff-elect makes the decision not to continue the awarded contract.

b. The Contractor or any of its principals are debarred, suspended, proposed for debarment or declared ineligible to participate in the State of Florida SPURS System under the provisions of Section 287.133(3)(a), Florida Statutes or pursuant to Rule 60A-1.006 F.A.C.

c. Insolvency, bankruptcy or receivership of the Contractor.

F. INSURANCE 1) The Contractor shall provide a certificate of insurance indicating that the following insurance requirements are in

force at the time of contract start date:

a) Workers Compensation: Statutory benefits with minimum employer's liability of $100,000 each accident.

b) General Liability: The Contractor shall warrant that it and all of its employees shall have general liability insurance coverage with minimum limits of $1,000,000 per occurrence and $2,000,000 in aggregate annually naming the CCSO as additionally insured.

c) Automobile Liability: Liability insurance covering all owned and hired vehicles used in connection with the Contractor's obligations under the awarded contract, of not less than $500,000 combined single limit per occurrence.

2) The Contractor shall be solely responsible for the payment for required coverage’s and the payment of any

deductibles required by said policies. 3) Any cancellation, reduction in value or lapse of insurance coverage shall be considered a material breach of the

awarded contract.

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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4) The Contractor shall be responsible in providing valid certificates of insurance with the requirements outlined above to CCSO throughout the duration of the contract term.

G. ADJUSTMENTS/MODIFICATIONS/AMENDMENTS 1) Should the Collier County Sheriff's Office and the Contractor mutually agree to a change in the scope of the

program during the contract term, a mutually agreed to price adjustment shall be allowed.

2) Changes in contractual provisions of services to be furnished under the contract may be made only in writing and must be approved mutually by an agent of the Contractor and the Sheriff's Office.

3) The Contractor shall give full attention to the faithful execution of the contract, shall keep the contract under his control, and shall not by power of attorney or otherwise assign the contract to any other party without prior written approval of the Sheriff.

4) Should laws change requiring additional services or significant changes in costs, the Contractor and the Collier County Sheriff's Office shall negotiate an equitable price adjustment.

5) During the term of the awarded contract, the Contractor shall furnish all of the services specified in the Request

for Quotation. 6) The Contractor understands and agrees that the awarded contract is a requirements contract and the Collier

County Sheriff's Office shall have no responsibility or obligation to the Contractor in providing contractor’s services.

7) All notices and requests by the Sheriff's Office or the Contractor shall be in writing and shall be delivered by

certified mail, return receipt requested, to the correct address of the parties to the contract. Either party may change its address by giving notice of the new address to the other party.

H. LIABILITIES 1) Indemnification: Contractor shall indemnify the CCSO against liability for any suits, actions, or claims of any

character arising from or relating to the Contractor's performance under the awarded contract.

a. The CCSO has no obligation to provide legal counsel or legal defense to the Contractor in the event that a suit, claim, or action of any character is brought by any person not party to the awarded contract against the Contractor as a result of or relating to the Contractor’s obligations under the awarded contract.

b. The CCSO has no obligation for the payment of any judgment or the settlement of any claims made against

the Contractor as a result of or relating to the Contractor’s obligations under the awarded contract.

c. The Contractor shall give immediate notice to the Sheriff or his designated representative of any claim or suit made or filed against the Contractor or any matter pertaining to the awarded contract.

d. The Contractor shall cooperate, assist and consult with the CCSO in any claim, suit or action made or filed

against the CCSO or Collier County as a result of or relating to the Contractor's obligations under the awarded contract.

I. OSHA COMPLIANCE The Contractor expressly agrees that it shall be solely responsible for supervising its employees, that it shall comply with all rules, regulations, orders, standards, and interpretations promulgated pursuant to the OSHA Act of 1970, including but not limited to training, recordkeeping, providing personal protective equipment, lockout/tagout procedures, material safety data sheets and labeling as required by the Right to Know Standards, 29 CFR 1910.1200.

INFORMAL RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

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J. INDEPENDENT CONTRACTOR The CCSO shall expressly acknowledge that the Contractor is an independent contractor, and nothing in their Agreement is intended nor shall it be construed to create an agency relationship, an employer/employee relationship, a joint venture relationship, or any other relationship allowing CCSO to exercise control or discretion over the manner or method by which the Contractor performs their obligations under their Agreement.

K. PERSONNEL Contractor certifies that it has, or shall secure at its own expense, all personnel required in performing the services under the awarded contract. Such personnel shall not be employees or have any contractual relationship with CCSO.

a. All of the services required hereunder shall be performed by the Contractor or under its supervision and all

personnel engaged in the work shall be fully qualified to perform such services.

L. LITAGATION COSTS All of the Contractor’s litigation costs including reasonable attorney fees, arising from disputes under the awarded contract shall be paid by the Contractor. M. CONFIDENTIALITY OF INFORMATION The Contractor shall agree that all CCSO files, records and electronic communications pertaining to the Contractor’s obligations under the awarded contract, are the exclusive property of CCSO and all information contained therein is confidential and is not to be discussed, copied, published or disseminated to any individual or organization outside of CCSO without the written approval of CCSO.

N. VENUE The CCSO and the Contractor shall agree that the awarded contract shall be a Florida contract to be performed in Florida, and further that any litigation arising thereunder shall be brought and completed in Collier County, Florida and other pertinent Florida courts, and further that neither party shall seek to remove such litigation from Circuit Courts or Appellate Courts of the State of Florida by application of conflict of laws or any other removal process. O. PREA COMPLIANCE The Collier County Sheriff's Office has a zero tolerance of sexual abuse or sexual harassment of inmates. CCSO adheres to the Prison Rape Elimination Act (PREA) of 2013. Per PREA standard 115.32, training will be provided by this agency for contracted employees and volunteers who may have contact with inmates. Per PREA standard 115.77, contractors or volunteers that engage in sexual abuse or harassment of inmates will be prohibited from continued contact with inmates. Violations will be reported to law enforcement and/or licensing bodies as applicable.

P. ASSIGNMENT Neither the awarded contract nor any of the Contractor’s obligations hereunder shall be transferred by the Contractor in whole or part without the expressed written permission of CCSO. Q. EQUAL EMPLOYMENT OPPORTUNITY The Contractor shall comply with all requirements of Federal, State and local regulations to ensure that no employee or applicant for employment is discriminated against because of race, religion, color, sex, age, handicap or national origin.

Disclaimer: Due care and diligence has been exercised in the preparation of this Request for Proposal, and all information contained herein is believed to be substantially correct.

RFQ #2015.003 MEDICAL AUDIT AND COMPLIANCE SERVICES

QUOTATION SUBMISSION AUTHORIZATION ATTACHMENT A

The person signing this quote certifies that he/she has the full level of authority and is authorized to commit the organization to the document and prices quoted. Quotes that are not signed by an authorized representative of the Respondent’sorganization will be eliminated.

The Respondent agrees this quote is in response to Collier County Sheriff’s Office, RFQ #2015.003 for Medical Audit and Compliance Services.

The Respondent agrees this is a corporation or other legal entity.

By signing below, the Respondent hereby certifies that:

Respondent has read and fully understands and agrees that acceptance by Collier County Sheriff’s Office (CCSO) of the Respondent’s offer by the issuance of a purchase order (PO) or contract will create a binding agreement;

Respondent agrees to fully comply with all the terms and conditions as set forth in the CCSO’s Agreement provisions, and amendments thereto, together with the specifications and other document forms herewith made part of this specific procurement;

The following may be considered as sufficient cause for disqualification:

1) Submission of more than one proposal for the same provision of services from an individual firm or corporation under the same or different names.

2) Evidence that the Proposer has a financial interest in the firm of another Proposer for the provision of the same services.

3) Evidence of collusion amongst Proposers. Participation in such collusion shall receive no recognition as Proposers for theprovision of any service until such participant has been reinstated as a qualified Proposer or a period of five years whicheveris greater.

4) Default under a previous contract for the provision of services and/or products to the Collier County Sheriff’s Office.

5) Failure of the Proposer to disclose at the time of proposal submission that any member of the Collier County Sheriff’s Office or immediate family member of a CCSO member has more than a five percent vested interest in the submitting company.

The Respondent agrees this is an irrevocable offer and will remain valid for 120 business days from the date of submission.

__________________________________________________________________________________________________Organization submitting quote

_______________________________________________________ ___________________________Address Telephone

_______________________________________________________ ___________________________City State Zip Code Fax

_______________________________________________________ __________________________Federal Tax ID Number Email

RFP #2015.003 - MEDICAL AUDIT & COMPLIANCE SERVICES

-$

Days Total Hours Costs

-$

-$

-$

-$

-$

-$

Printed Name of Authorized Individual Signature of Authorized Individual

Organization Name

The price and terms and conditions in this Quotation are valid for 120 days from the date of submission.

Price Proposal

Total Contract Cost (Quarterly consulting fees and reports)

Naples Jail Center On-site visits

A. Consulting Services (includes travel costs) Hourly Rate

Collier County Sheriff's Office

Quarterly Report Preparation (4 reports)

4th Quarter July 2016

1st Quarter November 2015

2nd Quarter February 2016

3rd Quarter May 2016

Date

RFQ #2015.003Medical Audit and Compliance Consulting Services Price Proposal

2015.003 MEDICAL AUDIT AND COMPLIANCE CONSULTING SERVICES

EXCEPTIONS TO SCOPE OF SERVICES ATTACHMENT C

Date: ____________________________

Business Name: _____________________________________________________________________Print Business Name

By: _______________________________________________________________________________Company Official Printed Name & Title

Note: Contractor shall list all “Exceptions to the Scope of Work.” The bidder must include alternative proposals to all exceptions noted. Failure to note any exceptions will signify the bidder’s agreement to comply with the Scope of Work as requested in this ITB/RFP/RFQ.

Check one that applies to this ITB/RFP below:

Contractor has NO “Exceptions” to the ITB/RFP/RFQ and complies with the Scope of Work.

OR

Contractor has “Exceptions” to the ITB/RFP/RFQ and they are listed below:

Exceptions – bidder to attach documents. All exceptions must be clearly identified by section then subsection.

Attachment D - Certificate of Insurance Questionnaire

Date: ____________________________

Insurance certificates shall be submitted by the awarded contractor to CCSO Purchasing Department before the contract commencement date. CCSO will be named the “Additional Insured” on the certificates. Mandated Coverage’s:

Worker’s Compensation Insurance at statutory limits, including employer’s liability coverage at minimum limits of per occurrence:

o $100,00 each accident o $100,00 by disease per occurrence o $500,000 aggregate by disease

Commercial Automobile Liability Insurance – Minimum combined single limits of:

o $500,000 per occurrence for bodily injury and property damage, including owned, non-owned

and hired car coverage.

General Liability Insurance covering all employees with minimum limits of:

o $1,000,000 per occurrence o $2,000,000 aggregate annually

I affirm that ______________________________________________ meets or exceeds the Print Company Name insurance requirements as stated above. I understand I must provide insurance certificates five business days prior to contract commencement. I certify our business meets or exceeds the coverage’s that CCSO mandates. Company representative name: ___________________________________

Signature: ____________________________________________________

ATTACHMENT E. Drug-Free Workplace

If the Proposer is an organization it must maintain a drug-free workplace policy or certificate and said document must include pre-employment and random drug screening of all employees. The Proposer shall certify at the time of submission of their proposal that such a program is in place and functioning. The Sheriff’s Office reserves the right to periodically request, during the term of the contract, proof that the drug-free workplace is being conscientiously applied.

Date: ____________________________________

Organization Name: ________________________________________________________________ Organization Representative’s Name: ___________________________________________________________ Organization Representative’s Title: _____________________________________________________________

Please select below the type of drug-free workplace that has been established by the organization. MUST ATTACH A CURRENT COPY OF THE SELECTED ITEM:

DRUG-FREE WORKPLACE CERTIFICATE and/or

DRUG-FREE WORKPLACE POLICY

Attachment F. Unauthorized Alien Statement Statement that the Contractor does not employ unauthorized aliens in accordance with section 274A (e) of the Immigration and Nationality Act (8 U.S.C. 1324a). Unauthorized Alien Statement This statement certifies ____________________________________________________ Print Company Name does not employ unauthorized aliens in accordance with Section 274(e) of the Immigration and Nationality Act (8 U.S.C. 1324a). Our company has employees of employment interest complete Form I-9, Employment Eligibility Verification supplied by the Department of Homeland Security, U.S. Citizenship and Immigration Services prior to employment. Signed By: ____________________________________________________________ Print Name: ____________________________________________________________ Print Title: ____________________________________________________________ Date: ____________________________________________________________ Sworn to an subscribed before me this ________________day of _____________, 19_________________ Personally known ____________________________________________________ OR produced identification _______________________________________________________ (Type of identification) Notary Public - State of ___________________ My commission expires____________________________________________________________________

(Printed typed or stamped commissioned name of notary public)

Attachment G. Equal Rights Act Statement

Date: ________________________________ By signing the statement below, I affirm our organization is in accordance with the provisions of Title VII of the 1968 Civil Rights Act as amended by the Equal Employment Opportunity Act of 1972 and Executive Order 11914, the Proposer in its employment practices shall not discriminate on the basis of race, color, sex, religion, age, national origin or disability. Organization’s name: ________________________________________________________________ Organization’s representative name and title: _____________________________________________ Organization’s representative signature: _________________________________________________ Our organization provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Our organization complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Our organization expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of our organization’s employees to perform their expected job duties is absolutely not tolerated.

REFERENCES ATTACHMENT H. Date: ____________________________ Business Name: _____________________________________________________________________

Print Business Name By: _______________________________________________________________________________ Company Official Printed Name & Title Note: Input references where similar services from the RFQ’s Scope of Services have been provided. One reference must be governmental. REFERENCE #1 GOVERNMENTAL COMPANY NAME: __________________________________________________________ ADDRESS: __________________________________________________________ CONTACT NAME: __________________________________________________________ CONTACT PHONE NUMBER: __________________________________________________________ CONTACT EMAIL: __________________________________________________________ REFERENCE #2 GOVERNMENTAL COMPANY NAME: __________________________________________________________ ADDRESS: __________________________________________________________ CONTACT NAME: __________________________________________________________ CONTACT PHONE NUMBER: __________________________________________________________ CONTACT EMAIL: __________________________________________________________ REFERENCE #3 GOVERNMENTAL COMPANY NAME: __________________________________________________________ ADDRESS: __________________________________________________________ CONTACT NAME: __________________________________________________________ CONTACT PHONE NUMBER: __________________________________________________________ CONTACT EMAIL: __________________________________________________________

Attachment I. PUBLIC ENTITY CRIME FORM

SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a), FLORIDA STATUTES, ON ENTITY CRIMES

1. This sworn statement is submitted to_____________________________________________________________________ (print name of the public entity) by_________________________________________________________________________________________________________ (print individual's name and title signing form) for________________________________________________________________________________________________________ (print name of entity submitting sworn statement) whose business address is _________________________________________________________________________________ and (if applicable) its Federal Employer Identification Number (FEIN) is_______________________________If the entity has no FEIN, include the Social Security Number of the Individual signing this sworn statement_______________________________. 2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g),Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision or any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of

guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

a. A predecessor or successor of a person convicted of a public entity crime; or

b. An entity under the control any natural person who is active in the management of the entity and who has

been convicted of a public entity crime. The term affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

c. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person

or entity organized under the laws of any state or of the United States with the legal power to enter into binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

d. Based on information and belief, the statement which I have marked below is true in relation to the entity

submitting this sworn statement.

(Place an X below for the statement that applies.)

_____ Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.

_____ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders,

employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.

_____ The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders,

employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (attach a copy of the final order)

I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT HIS FORM IS VALID THOROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. _________________________________________________________ (Company Official signature)

Sworn to an subscribed before me this ________________day of _____________, 19_________________ Personally known ____________________________________________________ OR produced identification _______________________________________________________ (Type of identification) Notary Public - State of ___________________ My commission expires____________________________________________________________________

(Printed typed or stamped commissioned name of notary public)